{
  "hospital_name": "Utah Valley Specialty Hospital",
  "last_updated_on": "2026-01-01",
  "version": "2.0.0",
  "hospital_location": [
    "Utah Valley Specialty Hospital",
    "Utah Valley Specialty Hospital - IRU"
  ],
  "hospital_address": [
    "306 W River Bend Ln, Provo, UT 84604",
    "306 West River Bend Lane, Provo, UT 84604"
  ],
  "license_information": {
    "state": "UT"
  },
  "affirmation": {
    "affirmation": "To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.",
    "confirm_affirmation": true
  },
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        {
          "code": "0120",
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            },
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            },
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            },
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            },
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              "payer_name": "Cigna Health and Life Insurance Company",
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              "methodology": "per diem"
            },
            {
              "payer_name": "LifePrint Health dba Optum Care",
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            },
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            },
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              "payer_name": "Aetna Network Services",
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            },
            {
              "payer_name": "Aetna Network Services",
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            },
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              "payer_name": "Regence Blue Cross Blue Shield",
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            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
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            },
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      "description": "Intensive Care Unit - Intermediate ICU",
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        {
          "code": "0206",
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            },
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            },
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            },
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              "payer_name": "Humana Insurance Company",
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            },
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              "payer_name": "Cigna Health and Life Insurance Company",
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            },
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              "payer_name": "Cigna Health and Life Insurance Company",
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            },
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            },
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            },
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              "payer_name": "SelectHealth Benefit Assurance Company",
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            },
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              "payer_name": "SelectHealth Benefit Assurance Company",
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            },
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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            },
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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            },
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              "payer_name": "Deseret Mutual Benefit Administrators",
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            },
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              "payer_name": "University of Utah Health Plan (UUHP)",
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            },
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            },
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              "payer_name": "University of Utah Health Plan (UUHP)",
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            },
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              "payer_name": "Regence Blue Cross Blue Shield",
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            },
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            },
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              "payer_name": "Regence Blue Cross Blue Shield",
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            },
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            },
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            },
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            },
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            },
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            },
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            },
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            },
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            },
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            },
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            },
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            },
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            }
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      ]
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    {
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            },
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              "payer_name": "Humana Insurance Company",
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            },
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              "payer_name": "Cigna Health and Life Insurance Company",
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              "methodology": "per diem"
            },
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              "payer_name": "Cigna Health and Life Insurance Company",
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            },
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            },
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              "payer_name": "LifePrint Health dba Optum Care",
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            },
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              "payer_name": "Coventry Health Care",
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              "methodology": "percent of total billed charges"
            },
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              "payer_name": "SelectHealth Benefit Assurance Company",
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            },
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Choice",
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            },
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Med",
              "standard_charge_dollar": 1200,
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            },
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Share",
              "standard_charge_dollar": 1200,
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            },
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Value",
              "standard_charge_dollar": 1200,
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            },
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              "payer_name": "Aetna Network Services",
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            },
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            },
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              "payer_name": "Aetna Network Services",
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            },
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              "payer_name": "Deseret Mutual Benefit Administrators",
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            },
            {
              "payer_name": "University of Utah Health Plan (UUHP)",
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            },
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              "payer_name": "University of Utah Health Plan (UUHP)",
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            },
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              "payer_name": "University of Utah Health Plan (UUHP)",
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            },
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              "payer_name": "Regence Blue Cross Blue Shield",
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            },
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            },
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            },
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              "methodology": "percent of total billed charges"
            },
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              "payer_name": "University of Utah Health Plan (UUHP)",
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            },
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              "payer_name": "Aetna Network Services",
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            },
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              "payer_name": "TriWest Healthcare Alliance Corporation",
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            },
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              "payer_name": "TriWest Healthcare Alliance Corporation",
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            }
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      "description": "Room & Board - Private (One Bed) - Rehabilitation",
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        {
          "code": "0118",
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      ],
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            },
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            },
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            },
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            },
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            },
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            },
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            },
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            },
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            },
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            },
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            }
          ],
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      "description": "Room & Board - Semi-private (Two Beds) - Rehabilitation",
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          "code": "0128",
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      ],
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            },
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            },
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            },
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            },
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            },
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            },
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            },
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            },
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      "description": "Room & Board - Three and Four Beds - Rehabilitation",
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      ],
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            },
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      "description": "Room & Board - Deluxe Private - Rehabilitation",
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      "description": "Room & Board - Ward - Rehabilitation",
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          ],
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    {
      "description": "Nervous System Neoplasms with MCC*",
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      "description": "Nervous System Neoplasms without MCC*",
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      ],
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            },
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            },
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      "description": "Degenerative Nervous System Disorders with MCC",
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          "code": "56",
          "type": "LOCAL"
        }
      ],
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      "description": "Other Ear, Nose, Mouth and Throat O.R. Procedures with MCC",
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      "description": "Other Ear, Nose, Mouth and Throat O.R. Procedures with CC",
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        {
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        {
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    {
      "description": "Other Ear, Nose, Mouth and Throat Diagnoses with MCC",
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          "code": "154",
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      ],
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      "description": "Complex Aortic Arch Procedures",
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      "description": "Cardiac Valve and Other Major Cardiothoracic Procedures with Cardiac Catheterization with MCC",
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      "description": "Cardiac Valve and Other Major Cardiothoracic Procedures without Cardiac Catheterization with MCC",
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      "description": "Circulatory Disorders Except AMI, with Cardiac Catheterization with MCC",
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      "description": "Acute and Subacute Endocarditis with MCC",
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        {
          "code": "288",
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      ],
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        {
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      "description": "Acute and Subacute Endocarditis without CC/MCC",
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      "description": "Heart Failure and Shock with MCC*",
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      "description": "Heart Failure and Shock without CC/MCC*",
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          "code": "293",
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      "description": "Cardiac Arrest, Unexplained with MCC",
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      "description": "Cardiac Arrest, Unexplained with CC",
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      "description": "Cardiac Arrest, Unexplained without CC/MCC",
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        {
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        }
      ],
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      "description": "Concomitant Left Atrial Appendage Closure and Cardiac Ablation",
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      "description": "Percutaneous Coronary Atherectomy without Intraluminal Device",
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      "description": "Other Endovascular Cardiac Valve Procedures with MCC",
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      "description": "Bilateral or Multiple Major Joint Procedures of Lower Extremity with MCC",
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        {
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      "description": "Multiple Level Combined Anterior and Posterior Spinal Fusion Except Cervical with MCC or Custom-Made Anatomically Designed Interbody Fusion Device",
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              "payer_name": "Molina Healthcare of Utah",
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Molina Healthcare of Utah",
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        {
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              "payer_name": "SelectHealth Benefit Assurance Company",
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            },
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              "payer_name": "Molina Healthcare of Utah",
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        {
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              "payer_name": "SelectHealth Benefit Assurance Company",
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              "payer_name": "Molina Healthcare of Utah",
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      "description": "Cirrhosis and Alcoholic Hepatitis with MCC*",
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          "code": "432",
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      ],
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        {
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              "payer_name": "Molina Healthcare of Utah",
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              "payer_name": "Humana Insurance Company",
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            },
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Molina Healthcare of Utah",
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            },
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              "payer_name": "Regence Blue Cross Blue Shield",
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      "description": "Cirrhosis and Alcoholic Hepatitis with CC*",
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          "code": "433",
          "type": "LOCAL"
        }
      ],
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        {
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            },
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              "payer_name": "Molina Healthcare of Utah",
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            },
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              "payer_name": "Humana Insurance Company",
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            },
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Humana Insurance Company",
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            },
            {
              "payer_name": "Humana Insurance Company",
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            },
            {
              "payer_name": "Molina Healthcare of Utah",
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            },
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              "payer_name": "Regence Blue Cross Blue Shield",
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      ]
    },
    {
      "description": "Disorders of the Biliary Tract with CC",
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        {
          "code": "445",
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      ],
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        {
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              "payer_name": "SelectHealth Benefit Assurance Company",
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            },
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      "description": "Disorders of the Biliary Tract without CC/MCC",
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        {
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              "payer_name": "SelectHealth Benefit Assurance Company",
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Molina Healthcare of Utah",
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            },
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              "payer_name": "Regence Blue Cross Blue Shield",
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            },
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      ]
    },
    {
      "description": "Multiple Level Spinal Fusion Except Cervical with MCC or Custom-Made Anatomically Designed Interbody Fusion Device",
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      ],
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        {
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              "payer_name": "SelectHealth Benefit Assurance Company",
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            },
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              "payer_name": "Molina Healthcare of Utah",
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            },
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              "payer_name": "Humana Insurance Company",
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            },
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Molina Healthcare of Utah",
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            },
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              "payer_name": "Regence Blue Cross Blue Shield",
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            },
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    {
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      ],
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        {
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              "payer_name": "Molina Healthcare of Utah",
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Molina Healthcare of Utah",
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            },
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              "payer_name": "Regence Blue Cross Blue Shield",
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            },
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    },
    {
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      ],
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        {
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              "payer_name": "SelectHealth Benefit Assurance Company",
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            },
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              "payer_name": "Molina Healthcare of Utah",
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              "payer_name": "Humana Insurance Company",
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            },
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              "payer_name": "Regence Blue Cross Blue Shield",
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            },
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              "payer_name": "Medicare (CMS)",
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          ],
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    {
      "description": "Single Level Spinal Fusion Except Cervical without MCC",
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        {
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        }
      ],
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        {
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              "payer_name": "SelectHealth Benefit Assurance Company",
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            },
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              "payer_name": "Molina Healthcare of Utah",
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            {
              "payer_name": "Humana Insurance Company",
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            },
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              "payer_name": "Humana Insurance Company",
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            },
            {
              "payer_name": "Molina Healthcare of Utah",
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            },
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              "payer_name": "Regence Blue Cross Blue Shield",
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            },
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              "payer_name": "Medicare (CMS)",
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            }
          ],
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      ]
    },
    {
      "description": "Bone Diseases and Arthropathies without MCC*",
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        {
          "code": "554",
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        }
      ],
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        {
          "setting": "inpatient",
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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            },
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              "payer_name": "Molina Healthcare of Utah",
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            },
            {
              "payer_name": "Humana Insurance Company",
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            },
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Molina Healthcare of Utah",
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            },
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              "payer_name": "Regence Blue Cross Blue Shield",
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            },
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              "payer_name": "Medicare (CMS)",
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            }
          ],
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    },
    {
      "description": "Signs and Symptoms of Musculoskeletal System and Connective Tissue with MCC",
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        {
          "code": "555",
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        }
      ],
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        {
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              "payer_name": "SelectHealth Benefit Assurance Company",
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            },
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              "payer_name": "Molina Healthcare of Utah",
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            },
            {
              "payer_name": "Humana Insurance Company",
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            },
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Molina Healthcare of Utah",
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            },
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              "payer_name": "Regence Blue Cross Blue Shield",
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            },
            {
              "payer_name": "Medicare (CMS)",
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    {
      "description": "Signs and Symptoms of Musculoskeletal System and Connective Tissue without MCC",
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        {
          "code": "556",
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        }
      ],
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        {
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              "payer_name": "SelectHealth Benefit Assurance Company",
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            },
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              "payer_name": "Molina Healthcare of Utah",
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            },
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              "payer_name": "Humana Insurance Company",
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            },
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Molina Healthcare of Utah",
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            },
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              "payer_name": "Regence Blue Cross Blue Shield",
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            },
            {
              "payer_name": "Medicare (CMS)",
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            }
          ],
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      ]
    },
    {
      "description": "Tendonitis, Myositis and Bursitis with MCC",
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        {
          "code": "557",
          "type": "LOCAL"
        }
      ],
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        {
          "setting": "inpatient",
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              "payer_name": "SelectHealth Benefit Assurance Company",
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              "methodology": "fee schedule"
            },
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              "payer_name": "Molina Healthcare of Utah",
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            },
            {
              "payer_name": "Humana Insurance Company",
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            },
            {
              "payer_name": "Humana Insurance Company",
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            },
            {
              "payer_name": "Humana Insurance Company",
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            },
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              "payer_name": "Molina Healthcare of Utah",
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
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            },
            {
              "payer_name": "Medicare (CMS)",
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      "description": "Skin Debridement with CC",
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      ],
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      "description": "Shoulder, Elbow or Forearm Procedures, Except Major Joint Procedures with CC",
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        {
          "code": "512",
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      "description": "Back and Neck Procedures Except Spinal Fusion with MCC or Disc Device or Neurostimulator",
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      "description": "Hip Replacement with Principal Diagnosis of Hip Fracture with MCC",
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      "description": "Other Infectious and Parasitic Diseases Diagnoses without CC/MCC",
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        {
          "code": "869",
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      "description": "Septicemia or Severe Sepsis with MV >96 Hours",
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        {
          "code": "870",
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          "code": "871",
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      "description": "Wound Debridements for Injuries with MCC",
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    {
      "description": "Other O.R. Procedures for Injuries with MCC*",
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      "description": "Major Male Pelvic Procedures with CC/MCC",
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      "description": "Other Injury, Poisoning and Toxic Effect Diagnoses with MCC",
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        {
          "code": "922",
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        {
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      "description": "Extensive Burns or Full Thickness Burns with MV >96 Hours with Skin Graft",
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        {
          "code": "927",
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      ],
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        {
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      "description": "Full Thickness Burn with Skin Graft or Inhalation Injury with CC/MCC",
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        {
          "code": "928",
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      ],
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        {
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      "description": "Extensive Burns or Full Thickness Burns with MV >96 Hours without Skin Graft",
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    {
      "description": "Full Thickness Burn without Skin Graft or Inhalation Injury",
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    {
      "description": "Non-Extensive Burns",
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      ],
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    {
      "description": "O.R. Procedures with Diagnoses of Other Contact with Health Services without CC/MCC",
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          "code": "941",
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        }
      ],
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              "payer_name": "Humana Insurance Company",
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            },
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        {
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    },
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      "description": "Other O.R. Procedures for Multiple Significant Trauma with MCC",
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      "description": "Other Multiple Significant Trauma with MCC*",
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            },
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            },
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            },
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            },
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            },
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      "description": "Other Multiple Significant Trauma with CC*",
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          "code": "964",
          "type": "LOCAL"
        }
      ],
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        {
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            },
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      ],
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        {
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            },
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          ],
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      ]
    },
    {
      "description": "HIV with Extensive O.R. Procedures with MCC",
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        {
          "code": "969",
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        }
      ],
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        {
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            },
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Molina Healthcare of Utah",
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            },
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              "payer_name": "Regence Blue Cross Blue Shield",
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            },
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    {
      "description": "HIV with Extensive O.R. Procedures without MCC",
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        {
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        }
      ],
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        {
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              "payer_name": "SelectHealth Benefit Assurance Company",
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Molina Healthcare of Utah",
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            },
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              "payer_name": "Regence Blue Cross Blue Shield",
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            },
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    },
    {
      "description": "HIV with Major Related Condition with MCC",
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          "code": "974",
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        }
      ],
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            },
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            },
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              "payer_name": "Molina Healthcare of Utah",
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              "payer_name": "Regence Blue Cross Blue Shield",
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            },
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              "payer_name": "Medicare (CMS)",
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      ]
    },
    {
      "description": "HIV with Major Related Condition with CC",
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        {
          "code": "975",
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        }
      ],
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        {
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              "payer_name": "SelectHealth Benefit Assurance Company",
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            },
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              "payer_name": "Molina Healthcare of Utah",
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              "payer_name": "Humana Insurance Company",
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            },
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              "payer_name": "Humana Insurance Company",
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            },
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              "payer_name": "Humana Insurance Company",
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            },
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              "payer_name": "Molina Healthcare of Utah",
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            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Medicare (CMS)",
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      ]
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    {
      "description": "HIV with Major Related Condition without CC/MCC",
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        {
          "code": "976",
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        }
      ],
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        {
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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            },
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              "payer_name": "Molina Healthcare of Utah",
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            },
            {
              "payer_name": "Humana Insurance Company",
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            },
            {
              "payer_name": "Humana Insurance Company",
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            },
            {
              "payer_name": "Humana Insurance Company",
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            },
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              "payer_name": "Molina Healthcare of Utah",
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            },
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              "payer_name": "Regence Blue Cross Blue Shield",
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            },
            {
              "payer_name": "Medicare (CMS)",
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            }
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      ]
    },
    {
      "description": "HIV with or without Other Related Condition",
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        {
          "code": "977",
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        }
      ],
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        {
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              "payer_name": "SelectHealth Benefit Assurance Company",
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            },
            {
              "payer_name": "Molina Healthcare of Utah",
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            },
            {
              "payer_name": "Humana Insurance Company",
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            },
            {
              "payer_name": "Humana Insurance Company",
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            },
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              "payer_name": "Molina Healthcare of Utah",
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            },
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              "payer_name": "Regence Blue Cross Blue Shield",
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            },
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    {
      "description": "Extensive O.R. Procedures Unrelated to Principal Diagnosis with MCC",
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        {
          "code": "981",
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        }
      ],
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        {
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            },
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            },
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              "payer_name": "Humana Insurance Company",
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            },
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    {
      "description": "Extensive O.R. Procedures Unrelated to Principal Diagnosis with CC",
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        }
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            },
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              "payer_name": "Regence Blue Cross Blue Shield",
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    {
      "description": "Extensive O.R. Procedures Unrelated to Principal Diagnosis without CC/MCC",
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        {
          "code": "983",
          "type": "LOCAL"
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        {
          "setting": "inpatient",
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              "payer_name": "SelectHealth Benefit Assurance Company",
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            },
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    {
      "description": "Non-Extensive O.R. Procedures Unrelated to Principal Diagnosis with MCC",
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        {
          "code": "987",
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      ],
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        {
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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    {
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          "code": "988",
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        {
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            },
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          ],
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      ]
    },
    {
      "description": "Non-Extensive O.R. Procedures Unrelated to Principal Diagnosis without CC/MCC",
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        {
          "code": "989",
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      ],
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        {
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            {
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            },
            {
              "payer_name": "Humana Insurance Company",
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            },
            {
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            },
            {
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            },
            {
              "payer_name": "Molina Healthcare of Utah",
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            },
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          ],
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      "description": "Pharmacy - General Classification",
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              "methodology": "percent of total billed charges"
            }
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    {
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          "code": "0257",
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          "setting": "outpatient",
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            {
              "payer_name": "Corvel Healthcare Corporation",
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              "methodology": "percent of total billed charges"
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          ],
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      ]
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      "description": "Laboratory - General Classification",
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          "code": "0300",
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        {
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              "payer_name": "Corvel Healthcare Corporation",
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              "payer_name": "Claritev fka MultiPlan",
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            },
            {
              "payer_name": "Coventry Health Care",
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            },
            {
              "payer_name": "Coventry Health Care",
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              "methodology": "percent of total billed charges"
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              "payer_name": "Aetna Network Services",
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              "estimated_amount": 516,
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            }
          ],
          "minimum": 360,
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      ]
    },
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      "description": "Laboratory - Chemistry",
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          "code": "0301",
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Corvel Healthcare Corporation",
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            {
              "payer_name": "Claritev fka MultiPlan",
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            },
            {
              "payer_name": "Coventry Health Care",
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            },
            {
              "payer_name": "Coventry Health Care",
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            },
            {
              "payer_name": "Aetna Network Services",
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              "estimated_amount": 99.46,
              "methodology": "percent of total billed charges"
            }
          ],
          "minimum": 99.46,
          "maximum": 229.5
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      ]
    },
    {
      "description": "Laboratory - Immunology",
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        {
          "code": "0302",
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      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Corvel Healthcare Corporation",
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              "standard_charge_percentage": 85,
              "estimated_amount": 104.64,
              "methodology": "percent of total billed charges"
            }
          ],
          "minimum": 104.64,
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      ]
    },
    {
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        {
          "code": "0305",
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      ],
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          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Corvel Healthcare Corporation",
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              "estimated_amount": 40.63,
              "methodology": "percent of total billed charges"
            }
          ],
          "minimum": 40.63,
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      ]
    },
    {
      "description": "Laboratory - Bacteriology & Microbiology",
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        {
          "code": "0306",
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      ],
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        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Corvel Healthcare Corporation",
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              "estimated_amount": 53.98,
              "methodology": "percent of total billed charges"
            }
          ],
          "minimum": 53.98,
          "maximum": 53.98
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      ]
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      "description": "Laboratory - Urology",
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          "code": "0307",
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      ],
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        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Corvel Healthcare Corporation",
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              "methodology": "percent of total billed charges"
            }
          ],
          "minimum": 237.15,
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        {
          "code": "0310",
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      ],
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        {
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            {
              "payer_name": "Corvel Healthcare Corporation",
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              "methodology": "percent of total billed charges"
            }
          ],
          "minimum": 116.25,
          "maximum": 116.25
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      ]
    },
    {
      "description": "Radiology - Diagnostic - General Classification",
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        {
          "code": "0320",
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      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Corvel Healthcare Corporation",
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              "methodology": "percent of total billed charges"
            }
          ],
          "minimum": 160.62,
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      ]
    },
    {
      "description": "Nuclear Medicine - General Classification",
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        {
          "code": "0340",
          "type": "RC"
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      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Corvel Healthcare Corporation",
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              "methodology": "percent of total billed charges"
            }
          ],
          "minimum": 4512.91,
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    },
    {
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        {
          "code": "0341",
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      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Corvel Healthcare Corporation",
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              "estimated_amount": 1094.8,
              "methodology": "percent of total billed charges"
            }
          ],
          "minimum": 1094.8,
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      ]
    },
    {
      "description": "Nuclear Medicine - Therapeutic Procedures",
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        {
          "code": "0342",
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      ],
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        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Corvel Healthcare Corporation",
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              "methodology": "percent of total billed charges"
            }
          ],
          "minimum": 702.95,
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    {
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        {
          "code": "0360",
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      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Corvel Healthcare Corporation",
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              "estimated_amount": 3662.21,
              "methodology": "percent of total billed charges"
            }
          ],
          "minimum": 3662.21,
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      ]
    },
    {
      "description": "Operating Room Services - Minor Surgery",
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          "code": "0361",
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      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Corvel Healthcare Corporation",
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              "estimated_amount": 539.75,
              "methodology": "percent of total billed charges"
            }
          ],
          "minimum": 539.75,
          "maximum": 539.75
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      ]
    },
    {
      "description": "Other Imaging Services - Diagnostic Mammography",
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        {
          "code": "0401",
          "type": "RC"
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      ],
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        {
          "setting": "outpatient",
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              "payer_name": "Corvel Healthcare Corporation",
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              "methodology": "percent of total billed charges"
            }
          ],
          "minimum": 259.25,
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      ]
    },
    {
      "description": "Other Imaging Services - Ultrasound",
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          "code": "0402",
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      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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            {
              "payer_name": "Corvel Healthcare Corporation",
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              "estimated_amount": 72.25,
              "methodology": "percent of total billed charges"
            }
          ],
          "minimum": 72.25,
          "maximum": 72.25
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      ]
    },
    {
      "description": "Other Imaging Services - Positron Emission Tomography",
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        {
          "code": "0404",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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            {
              "payer_name": "Corvel Healthcare Corporation",
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              "estimated_amount": 4176.73,
              "methodology": "percent of total billed charges"
            }
          ],
          "minimum": 4176.73,
          "maximum": 4176.73
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      ]
    },
    {
      "description": "CT Scan - General Classification",
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        {
          "code": "0350",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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            {
              "payer_name": "Corvel Healthcare Corporation",
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              "estimated_amount": 734.64,
              "methodology": "percent of total billed charges"
            }
          ],
          "minimum": 734.64,
          "maximum": 734.64
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      ]
    },
    {
      "description": "CT Scan - Head Scan",
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        {
          "code": "0351",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Corvel Healthcare Corporation",
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              "standard_charge_percentage": 85,
              "estimated_amount": 1158.14,
              "methodology": "percent of total billed charges"
            }
          ],
          "minimum": 1158.14,
          "maximum": 1158.14
        }
      ]
    },
    {
      "description": "CT Scan - Body Scan",
      "code_information": [
        {
          "code": "0352",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Corvel Healthcare Corporation",
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              "estimated_amount": 603.4,
              "methodology": "percent of total billed charges"
            }
          ],
          "minimum": 603.4,
          "maximum": 603.4
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      ]
    },
    {
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        {
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        {
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          "type": "RC"
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        {
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      ],
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        {
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      "description": "Magnetic Resonance Technology (MRT) - MRI - Other",
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          "code": "0614",
          "type": "RC"
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      ],
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        {
          "setting": "outpatient",
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              "estimated_amount": 1207.31,
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          ],
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          "code": "0615",
          "type": "RC"
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      ],
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        {
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              "payer_name": "Corvel Healthcare Corporation",
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              "estimated_amount": 1499.16,
              "methodology": "percent of total billed charges"
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          ],
          "minimum": 1499.16,
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    {
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        {
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      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Corvel Healthcare Corporation",
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            }
          ],
          "minimum": 2068.15,
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    {
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        {
          "code": "0618",
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        {
          "setting": "outpatient",
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              "payer_name": "Corvel Healthcare Corporation",
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              "estimated_amount": 2059.31,
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            }
          ],
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    {
      "description": "Respiratory Services - General Classification",
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        {
          "code": "0410",
          "type": "RC"
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      ],
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        {
          "setting": "outpatient",
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            },
            {
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              "methodology": "percent of total billed charges"
            },
            {
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              "estimated_amount": 306.6,
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            },
            {
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              "standard_charge_percentage": 70,
              "estimated_amount": 99.4,
              "methodology": "percent of total billed charges"
            },
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              "estimated_amount": 113.6,
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          ],
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      "description": "Respiratory Services - Inhalation Services",
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          "code": "0412",
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      ],
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        {
          "setting": "outpatient",
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              "payer_name": "Corvel Healthcare Corporation",
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              "estimated_amount": 467.5,
              "methodology": "percent of total billed charges"
            }
          ],
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          "code": "0413",
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        {
          "setting": "outpatient",
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          ],
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      ]
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    {
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          "code": "0420",
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      ],
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        {
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            },
            {
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            {
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            },
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            },
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            }
          ],
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      ]
    },
    {
      "description": "Physical Therapy - Visit Charge",
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          "code": "0421",
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      ],
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        {
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          ],
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    },
    {
      "description": "Physical Therapy - Hourly Charge",
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        {
          "code": "0422",
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      ],
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          ],
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      ]
    },
    {
      "description": "Physical Therapy - Group Rate",
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        {
          "code": "0423",
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      ],
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        {
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          ],
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      ]
    },
    {
      "description": "Physical Therapy - Evaluation or Re-evaluation",
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        {
          "code": "0424",
          "type": "RC"
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      ],
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        {
          "setting": "outpatient",
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            },
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            },
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            },
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          ],
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      ]
    },
    {
      "description": "Physical Therapy - Treatment",
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        {
          "code": "0425",
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      ],
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        {
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          ],
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      ]
    },
    {
      "description": "Physical Therapy - Continuation",
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        {
          "code": "0426",
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      ],
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          ],
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      ]
    },
    {
      "description": "Physical Therapy - Observation/Hourly",
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        {
          "code": "0427",
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      ],
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    },
    {
      "description": "Physical Therapy - Other",
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      ],
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    {
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      ],
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    {
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      ],
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            },
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          ],
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    },
    {
      "description": "Occupational Therapy - Visit Charge",
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        {
          "code": "0431",
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      ],
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        {
          "setting": "outpatient",
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              "payer_name": "LifePrint Health dba Optum Care",
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            },
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              "payer_name": "University of Utah Health Plan (UUHP)",
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    },
    {
      "description": "Occupational Therapy - Hourly Charge",
      "code_information": [
        {
          "code": "0432",
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    {
      "description": "Inj ronzanolixizum-noli 1 mg",
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    },
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        {
          "code": "J1190",
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        {
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      ],
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        {
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        {
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        {
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            {
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            {
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    },
    {
      "description": "Rasburicase",
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        {
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        {
          "code": "00024-5150-10",
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      ],
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        {
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              "estimated_amount": 369.97,
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            },
            {
              "payer_name": "Humana Insurance Company",
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            },
            {
              "payer_name": "Humana Insurance Company",
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      "description": "Dactinomycin injection",
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        {
          "code": "J9120",
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        {
          "code": "39822-2100-02",
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      ],
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        {
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            },
            {
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            },
            {
              "payer_name": "Humana Insurance Company",
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      ],
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        {
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            {
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              "estimated_amount": 4.12,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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            {
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          ],
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    {
      "description": "Ketorolac tromethamine inj",
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          "code": "J1885",
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        {
          "code": "00338-0069-10",
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      ],
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        {
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            {
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            },
            {
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            {
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              "payer_name": "Humana Insurance Company",
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            {
              "payer_name": "Humana Insurance Company",
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            },
            {
              "payer_name": "Humana Insurance Company",
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    {
      "description": "Inj cefazolin sodium, hikma",
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        {
          "code": "J0688",
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        {
          "code": "00143-9139-25",
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      ],
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        {
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            {
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              "estimated_amount": 1,
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            },
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 1,
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            },
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 1,
              "methodology": "fee schedule"
            }
          ],
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    {
      "description": "Inj, daptomycin (xellia)",
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          "code": "J0873",
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        {
          "code": "70594-0053-01",
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      ],
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        {
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          "payers_information": [
            {
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              "estimated_amount": 0.04,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 0.04,
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            },
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 0.04,
              "methodology": "fee schedule"
            }
          ],
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    },
    {
      "description": "Injection, hydromorphone, 0.1 mg",
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        {
          "code": "J1171",
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        {
          "code": "00409-1283-31",
          "type": "NDC"
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      ],
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        {
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          "payers_information": [
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              "payer_name": "SelectHealth Benefit Assurance Company",
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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            },
            {
              "payer_name": "Humana Insurance Company",
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            },
            {
              "payer_name": "Humana Insurance Company",
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              "standard_charge_percentage": 100,
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              "methodology": "fee schedule"
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            {
              "payer_name": "Regence Blue Cross Blue Shield",
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      "description": "Inj, glycopyrrolate, 0.1 mg",
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          "code": "J1596",
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        {
          "code": "00517-4601-25",
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      "description": "Inj, bumetanide, 0.5 mg",
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          "code": "J1939",
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        {
          "code": "00641-6284-10",
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      ],
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            {
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            },
            {
              "payer_name": "Humana Insurance Company",
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    {
      "description": "Inj fluphenazine hcl 1.25 mg",
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        {
          "code": "J2679",
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      ],
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        {
          "setting": "outpatient",
          "payers_information": [
            {
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              "methodology": "fee schedule"
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            {
              "payer_name": "Humana Insurance Company",
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            {
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    {
      "description": "Leuprolide acetate /3.75 mg",
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        {
          "code": "J1950",
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        {
          "code": "00074-2108-03",
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              "methodology": "fee schedule"
            },
            {
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            {
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    },
    {
      "description": "Injection, methylprednisolone sodium succinate, 5 mg",
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        {
          "code": "J2919",
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        {
          "code": "00009-0039-06",
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      ],
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            {
              "payer_name": "Humana Insurance Company",
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            },
            {
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            },
            {
              "payer_name": "Humana Insurance Company",
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            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
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    },
    {
      "description": "Inj, hydroxocobalamin",
      "code_information": [
        {
          "code": "J3425",
          "type": "HCPCS"
        },
        {
          "code": "00591-2888-30",
          "type": "NDC"
        }
      ],
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        {
          "setting": "outpatient",
          "payers_information": [
            {
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            },
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 0.01,
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    },
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      "description": "Inj melpha hydroch nos 50 mg",
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        {
          "code": "J9245",
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        {
          "code": "23155-0355-41",
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      ],
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        {
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      "description": "Pegaspargase injection",
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        {
          "code": "J9266",
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        {
          "code": "00944-3810-01",
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        {
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      "description": "Pentostatin injection",
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          "code": "J9268",
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      "description": "Inj cladribine per 1 mg",
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        {
          "code": "J9065",
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        {
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      "description": "Mitoxantrone hydrochl / 5 mg",
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        {
          "code": "J9293",
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        {
          "code": "00703-4680-01",
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        {
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        {
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      "description": "Lymphocyte immune globulin",
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      "description": "Alpha 1 proteinase inhibitor",
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      "description": "Injection,onabotulinumtoxina",
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      "description": "Cytomegalovirus imm iv /vial",
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        {
          "code": "J0850",
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        {
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    {
      "description": "Factor viii recombinant nos",
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          "code": "J7192",
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        {
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      "description": "Factor ix non-recombinant",
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        {
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        {
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            },
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      "description": "Octagam injection",
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          "code": "J1568",
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        {
          "code": "00069-6002-02",
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            },
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              "payer_name": "Humana Insurance Company",
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            },
            {
              "payer_name": "Health Choice Utah",
              "plan_name": "Utah Medicaid Program",
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              "methodology": "fee schedule"
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    {
      "description": "Gammagard liquid injection",
      "code_information": [
        {
          "code": "J1569",
          "type": "HCPCS"
        },
        {
          "code": "00944-2700-02",
          "type": "NDC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 46.46,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 46.46,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 46.46,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 46.46,
          "maximum": 46.46
        }
      ],
      "drug_information": {
        "unit": "10",
        "type": "ML"
      }
    },
    {
      "description": "Hepagam b im injection",
      "code_information": [
        {
          "code": "J1571",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 65.94,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 65.94,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 65.94,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 65.94,
          "maximum": 65.94
        }
      ]
    },
    {
      "description": "Gamunex-c/gammaked",
      "code_information": [
        {
          "code": "J1561",
          "type": "HCPCS"
        },
        {
          "code": "13533-0800-12",
          "type": "NDC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 49.01,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 49.01,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 49.01,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Health Choice Utah",
              "plan_name": "Utah Medicaid Program",
              "standard_charge_percentage": 100,
              "estimated_amount": 48.96,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 48.96,
          "maximum": 49.01
        }
      ],
      "drug_information": {
        "unit": "10",
        "type": "ML"
      }
    },
    {
      "description": "Albumin (human), 5%, 250 ml",
      "code_information": [
        {
          "code": "P9045",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 53.08,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 53.08,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 53.08,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 53.08,
          "maximum": 53.08
        }
      ]
    },
    {
      "description": "Albumin (human), 25%, 20 ml",
      "code_information": [
        {
          "code": "P9046",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 21.23,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 21.23,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 21.23,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 21.23,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 21.23,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 21.23,
          "maximum": 21.23
        }
      ]
    },
    {
      "description": "Hepagam b intravenous, inj",
      "code_information": [
        {
          "code": "J1573",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 65.94,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 65.94,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 65.94,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 65.94,
          "maximum": 65.94
        }
      ]
    },
    {
      "description": "Protein c concentrate",
      "code_information": [
        {
          "code": "J2724",
          "type": "HCPCS"
        },
        {
          "code": "00944-4177-05",
          "type": "NDC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 15.03,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 15.03,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 15.03,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 15.03,
          "maximum": 15.03
        }
      ],
      "drug_information": {
        "unit": "1",
        "type": "EA"
      }
    },
    {
      "description": "Supprelin la implant",
      "code_information": [
        {
          "code": "J9226",
          "type": "HCPCS"
        },
        {
          "code": "67979-0002-01",
          "type": "NDC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 45261.8,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 45261.8,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 45261.8,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 45261.8,
          "maximum": 45261.8
        }
      ],
      "drug_information": {
        "unit": "1",
        "type": "EA"
      }
    },
    {
      "description": "Temsirolimus injection",
      "code_information": [
        {
          "code": "J9330",
          "type": "HCPCS"
        },
        {
          "code": "16729-0223-61",
          "type": "NDC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 29.52,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 29.52,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 29.52,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 29.52,
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      ],
      "drug_information": {
        "unit": "1",
        "type": "ML"
      }
    },
    {
      "description": "Busulfan injection",
      "code_information": [
        {
          "code": "J0594",
          "type": "HCPCS"
        },
        {
          "code": "00409-1112-01",
          "type": "NDC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 1.42,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 1.42,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 1.42,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 1.42,
          "maximum": 1.42
        }
      ],
      "drug_information": {
        "unit": "10",
        "type": "ML"
      }
    },
    {
      "description": "Verteporfin injection",
      "code_information": [
        {
          "code": "J3396",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 11.5,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 11.5,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 11.5,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 11.5,
          "maximum": 11.5
        }
      ]
    },
    {
      "description": "Octreotide injection, depot",
      "code_information": [
        {
          "code": "J2353",
          "type": "HCPCS"
        },
        {
          "code": "00078-0790-61",
          "type": "NDC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 218.37,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 218.37,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 218.37,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 218.37,
          "maximum": 218.37
        }
      ],
      "drug_information": {
        "unit": "1",
        "type": "EA"
      }
    },
    {
      "description": "Antihemophilic viii/vwf comp",
      "code_information": [
        {
          "code": "J7186",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 1.2,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 1.2,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 1.2,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 1.2,
          "maximum": 1.2
        }
      ]
    },
    {
      "description": "Inj ivig privigen 500 mg",
      "code_information": [
        {
          "code": "J1459",
          "type": "HCPCS"
        },
        {
          "code": "44206-0436-05",
          "type": "NDC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 49.28,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 49.28,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 49.28,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Health Choice Utah",
              "plan_name": "Utah Medicaid Program",
              "standard_charge_percentage": 100,
              "estimated_amount": 50.74,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 49.28,
          "maximum": 50.74
        }
      ],
      "drug_information": {
        "unit": "1",
        "type": "ML"
      }
    },
    {
      "description": "Mitomycin injection",
      "code_information": [
        {
          "code": "J9280",
          "type": "HCPCS"
        },
        {
          "code": "00143-9135-01",
          "type": "NDC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 46.35,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 46.35,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 46.35,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 46.35,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 46.35,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 46.35,
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      ],
      "drug_information": {
        "unit": "1",
        "type": "EA"
      }
    },
    {
      "description": "Valrubicin injection",
      "code_information": [
        {
          "code": "J9357",
          "type": "HCPCS"
        },
        {
          "code": "24201-0101-04",
          "type": "NDC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 1392.52,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 1392.52,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 1392.52,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 1392.52,
          "maximum": 1392.52
        }
      ],
      "drug_information": {
        "unit": "5",
        "type": "ML"
      }
    },
    {
      "description": "Inj iron dextran",
      "code_information": [
        {
          "code": "J1750",
          "type": "HCPCS"
        },
        {
          "code": "00023-6082-10",
          "type": "NDC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 17.4,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 17.4,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 17.4,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 17.4,
          "maximum": 17.4
        }
      ],
      "drug_information": {
        "unit": "2",
        "type": "ML"
      }
    },
    {
      "description": "Antithrombin iii injection",
      "code_information": [
        {
          "code": "J7197",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 3.96,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 3.96,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 3.96,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 3.96,
          "maximum": 3.96
        }
      ]
    },
    {
      "description": "Xyntha inj",
      "code_information": [
        {
          "code": "J7185",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 1.5,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 1.5,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 1.5,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 1.5,
          "maximum": 1.5
        }
      ]
    },
    {
      "description": "Edetate calcium disodium inj",
      "code_information": [
        {
          "code": "J0600",
          "type": "HCPCS"
        },
        {
          "code": "49452-2697-01",
          "type": "NDC"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Humana Insurance Company",
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              "standard_charge_percentage": 100,
              "estimated_amount": 6084.1,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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            },
            {
              "payer_name": "Humana Insurance Company",
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          ],
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        "unit": "125",
        "type": "GM"
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    },
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      "description": "Abobotulinumtoxina",
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        {
          "code": "J0586",
          "type": "HCPCS"
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        {
          "code": "15054-0500-01",
          "type": "NDC"
        }
      ],
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        {
          "setting": "outpatient",
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            {
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              "methodology": "fee schedule"
            },
            {
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            {
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    },
    {
      "description": "Degarelix injection",
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        {
          "code": "J9155",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
            },
            {
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              "estimated_amount": 4.28,
              "methodology": "fee schedule"
            },
            {
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          ],
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      ]
    },
    {
      "description": "Ferumoxytol, non-esrd",
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        {
          "code": "Q0138",
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      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
            },
            {
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              "estimated_amount": 0.38,
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            {
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      ]
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    {
      "description": "Canakinumab injection",
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        {
          "code": "J0638",
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        {
          "code": "00078-0734-61",
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      ],
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        {
          "setting": "outpatient",
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            {
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            },
            {
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              "estimated_amount": 135.88,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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          ],
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    },
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      "description": "Hizentra injection",
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        {
          "code": "J1559",
          "type": "HCPCS"
        },
        {
          "code": "44206-0451-01",
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      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 13.64,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "standard_charge_percentage": 100,
              "estimated_amount": 13.64,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 13.64,
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          ],
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    },
    {
      "description": "Imuglucerase injection",
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        {
          "code": "J1786",
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        }
      ],
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        {
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            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 43.38,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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            },
            {
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              "estimated_amount": 43.38,
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    {
      "description": "Olanzapine long-acting inj",
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        {
          "code": "J2358",
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        }
      ],
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        {
          "setting": "outpatient",
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            {
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              "estimated_amount": 2.92,
              "methodology": "fee schedule"
            },
            {
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    {
      "description": "Collagenase, clost hist inj",
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        {
          "code": "J0775",
          "type": "HCPCS"
        }
      ],
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        {
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            {
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              "methodology": "fee schedule"
            },
            {
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    {
      "description": "Wilate injection",
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        {
          "code": "J7183",
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        }
      ],
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        {
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            {
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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            },
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 1.28,
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          ],
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    {
      "description": "Belimumab injection",
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        {
          "code": "J0490",
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      ],
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        {
          "setting": "outpatient",
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            {
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              "estimated_amount": 54.91,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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            {
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          ],
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    },
    {
      "description": "Lumizyme injection",
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        {
          "code": "J0221",
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        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 201.64,
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            },
            {
              "payer_name": "Humana Insurance Company",
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            },
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 201.64,
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          ],
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    },
    {
      "description": "Glassia injection",
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        {
          "code": "J0257",
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        {
          "code": "00944-2884-01",
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        }
      ],
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        {
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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          ],
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    },
    {
      "description": "Factor xiii anti-hem factor",
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        {
          "code": "J7180",
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        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
            },
            {
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            },
            {
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    {
      "description": "Gel-one",
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        {
          "code": "J7326",
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        }
      ],
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        {
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            {
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            },
            {
              "payer_name": "Humana Insurance Company",
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            },
            {
              "payer_name": "Humana Insurance Company",
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          ],
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    {
      "description": "Aflibercept injection",
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        {
          "code": "J0178",
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        },
        {
          "code": "61755-0005-01",
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        }
      ],
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        {
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            {
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 801.07,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
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          ],
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      "description": "Eribulin mesylate injection",
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        {
          "code": "J9179",
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        }
      ],
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        {
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            {
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "standard_charge_percentage": 100,
              "estimated_amount": 133.32,
              "methodology": "fee schedule"
            },
            {
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          ],
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    },
    {
      "description": "Calcitonin salmon injection",
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        {
          "code": "J0630",
          "type": "HCPCS"
        },
        {
          "code": "24201-0400-02",
          "type": "NDC"
        }
      ],
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        {
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            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 1142.41,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 1142.41,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "standard_charge_percentage": 100,
              "estimated_amount": 1142.41,
              "methodology": "fee schedule"
            }
          ],
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    },
    {
      "description": "Inj desmopressin acetate",
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        {
          "code": "J2597",
          "type": "HCPCS"
        },
        {
          "code": "00409-2265-01",
          "type": "NDC"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Humana Insurance Company",
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              "standard_charge_percentage": 100,
              "estimated_amount": 4.95,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "standard_charge_percentage": 100,
              "estimated_amount": 4.95,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 4.95,
              "methodology": "fee schedule"
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      ],
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    },
    {
      "description": "Phentolaine mesylate inj",
      "code_information": [
        {
          "code": "J2760",
          "type": "HCPCS"
        },
        {
          "code": "00143-9564-10",
          "type": "NDC"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
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              "estimated_amount": 394.63,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 394.63,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 394.63,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 394.63,
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      ],
      "drug_information": {
        "unit": "10",
        "type": "EA"
      }
    },
    {
      "description": "Inj aripiprazole ext rel 1mg",
      "code_information": [
        {
          "code": "J0401",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 7.07,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 7.07,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
            }
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      ]
    },
    {
      "description": "Inj filgrastim excl biosimil",
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        {
          "code": "J1442",
          "type": "HCPCS"
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        {
          "code": "55513-0209-01",
          "type": "NDC"
        }
      ],
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        {
          "setting": "outpatient",
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            {
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              "methodology": "fee schedule"
            },
            {
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              "methodology": "fee schedule"
            },
            {
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          ],
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      ],
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    },
    {
      "description": "Injection, pertuzumab, 1 mg",
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        {
          "code": "J9306",
          "type": "HCPCS"
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      ],
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        {
          "setting": "outpatient",
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
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            {
              "payer_name": "Humana Insurance Company",
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          ],
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    },
    {
      "description": "Inj beta interferon im 1 mcg",
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        {
          "code": "Q3027",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 55.62,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 55.62,
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            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 55.62,
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    {
      "description": "Certolizumab pegol inj 1mg",
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        {
          "code": "J0717",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 3.9,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 3.9,
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              "payer_name": "Humana Insurance Company",
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          ],
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    },
    {
      "description": "Golimumab for iv use 1mg",
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        {
          "code": "J1602",
          "type": "HCPCS"
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      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 10.54,
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            },
            {
              "payer_name": "Humana Insurance Company",
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            {
              "payer_name": "Humana Insurance Company",
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    },
    {
      "description": "Obinutuzumab inj",
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        {
          "code": "J9301",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 74.83,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 74.83,
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            },
            {
              "payer_name": "Humana Insurance Company",
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              "standard_charge_percentage": 100,
              "estimated_amount": 74.83,
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          ],
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      ]
    },
    {
      "description": "Inj human fibrinogen con nos",
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        {
          "code": "J7178",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 1.48,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 1.48,
              "methodology": "fee schedule"
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            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 1.48,
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          ],
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    },
    {
      "description": "Elosulfase alfa, injection",
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        {
          "code": "J1322",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 293.92,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 293.92,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "standard_charge_percentage": 100,
              "estimated_amount": 293.92,
              "methodology": "fee schedule"
            }
          ],
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    },
    {
      "description": "Darbepoetin alfa, esrd use",
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        {
          "code": "J0882",
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      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 2.97,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 2.97,
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            },
            {
              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
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          ],
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    },
    {
      "description": "Ferumoxytol, esrd use",
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        {
          "code": "Q0139",
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      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 0.38,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 0.38,
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          ],
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    },
    {
      "description": "Factor ix alprolix recomb",
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        {
          "code": "J7201",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "standard_charge_percentage": 100,
              "estimated_amount": 3.58,
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          ],
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    },
    {
      "description": "Injection, ramucirumab",
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        {
          "code": "J9308",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 72.91,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 72.91,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "standard_charge_percentage": 100,
              "estimated_amount": 72.91,
              "methodology": "fee schedule"
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          ],
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      ]
    },
    {
      "description": "Injection, vedolizumab",
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        {
          "code": "J3380",
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        },
        {
          "code": "64764-0300-20",
          "type": "NDC"
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      ],
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        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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          ],
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      ],
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        "unit": "1",
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    },
    {
      "description": "Inj pembrolizumab",
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        {
          "code": "J9271",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 57.6,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 57.6,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 57.6,
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          ],
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      ]
    },
    {
      "description": "Ethanolamine oleate 100 mg",
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        {
          "code": "J1430",
          "type": "HCPCS"
        },
        {
          "code": "67871-4790-06",
          "type": "NDC"
        }
      ],
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        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 491.65,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "standard_charge_percentage": 100,
              "estimated_amount": 491.65,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "standard_charge_percentage": 100,
              "estimated_amount": 491.65,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 491.65,
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        "unit": "2",
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    },
    {
      "description": "Hemin, 1 mg",
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        {
          "code": "J1640",
          "type": "HCPCS"
        },
        {
          "code": "55292-0702-54",
          "type": "NDC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 33.12,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 33.12,
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        "unit": "1",
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    },
    {
      "description": "Ziconotide injection",
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        {
          "code": "J2278",
          "type": "HCPCS"
        },
        {
          "code": "18860-0720-10",
          "type": "NDC"
        }
      ],
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        {
          "setting": "outpatient",
          "payers_information": [
            {
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 9.78,
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            }
          ],
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      ],
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    },
    {
      "description": "Palifermin injection",
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        {
          "code": "J2425",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 33.99,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 33.99,
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    },
    {
      "description": "Treprostinil injection",
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        {
          "code": "J3285",
          "type": "HCPCS"
        },
        {
          "code": "00703-0666-01",
          "type": "NDC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 55.95,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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            }
          ],
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        "unit": "20",
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      }
    },
    {
      "description": "Humate-p, inj",
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        {
          "code": "J7187",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 1.45,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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            }
          ],
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      ]
    },
    {
      "description": "Factor viia recomb novoseven",
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        {
          "code": "J7189",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 2.55,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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            }
          ],
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      ]
    },
    {
      "description": "Clofarabine injection",
      "code_information": [
        {
          "code": "J9027",
          "type": "HCPCS"
        },
        {
          "code": "00024-5860-01",
          "type": "NDC"
        }
      ],
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        {
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              "payer_name": "Humana Insurance Company",
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    },
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      "description": "Paclitaxel protein bound",
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        {
          "code": "J9264",
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        {
          "code": "00480-3290-01",
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      ],
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        {
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    },
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      "description": "Factor xiii recomb a-subunit",
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        {
          "code": "J7181",
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      ],
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        {
          "setting": "outpatient",
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            {
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            {
              "payer_name": "Humana Insurance Company",
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    {
      "description": "Monovisc inj per dose",
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        {
          "code": "J7327",
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      ],
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        {
          "setting": "outpatient",
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            {
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            },
            {
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    {
      "description": "Inj tbo filgrastim 1 microg",
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        {
          "code": "J1447",
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        {
          "code": "63459-0918-59",
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      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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            },
            {
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            {
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            {
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              "payer_name": "Regence Blue Cross Blue Shield",
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          ],
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    {
      "description": "Rolapitant, oral, 1mg",
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        {
          "code": "J8670",
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        {
          "code": "69656-0101-02",
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        {
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            {
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            {
              "payer_name": "Humana Insurance Company",
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    {
      "description": "Injection, alemtuzumab",
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        {
          "code": "J0202",
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      ],
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        {
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            {
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            {
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        {
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        {
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      "description": "Injection, dalbavancin",
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          "code": "J0875",
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        {
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      "description": "Ceftaroline fosamil inj",
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        {
          "code": "J0712",
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        {
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      "description": "Hyqvia 100mg immuneglobulin",
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          "code": "J1575",
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        {
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            {
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            {
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      "description": "Factor viii recomb obizur",
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        {
          "code": "J7188",
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      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Humana Insurance Company",
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            {
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            {
              "payer_name": "Humana Insurance Company",
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      "description": "Penicillin g benzathine inj",
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        {
          "code": "J0561",
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        {
          "code": "54868-0753-00",
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        {
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            {
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            {
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    {
      "description": "Dimethyl sulfoxide 50% 50 ml",
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        {
          "code": "J1212",
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        {
          "code": "10106-9224-01",
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      ],
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        {
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            {
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              "methodology": "fee schedule"
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            {
              "payer_name": "Humana Insurance Company",
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            {
              "payer_name": "Humana Insurance Company",
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    },
    {
      "description": "Factor viii pegylated recomb",
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        {
          "code": "J7207",
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      ],
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        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Humana Insurance Company",
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            },
            {
              "payer_name": "Humana Insurance Company",
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            {
              "payer_name": "Humana Insurance Company",
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            }
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    },
    {
      "description": "Factor viii nuwiq recomb 1iu",
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        {
          "code": "J7209",
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      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Humana Insurance Company",
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              "payer_name": "Humana Insurance Company",
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      "description": "Injection, inflectra",
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        {
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        {
          "code": "00069-0809-01",
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      ],
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        {
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            {
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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        "unit": "1",
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    },
    {
      "description": "Foscarnet sodium injection",
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        {
          "code": "J1455",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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            }
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    },
    {
      "description": "Gamma globulin 1 cc inj",
      "code_information": [
        {
          "code": "J1460",
          "type": "HCPCS"
        },
        {
          "code": "13533-0335-04",
          "type": "NDC"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
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      ],
      "drug_information": {
        "unit": "2",
        "type": "ML"
      }
    },
    {
      "description": "Gamma globulin > 10 cc inj",
      "code_information": [
        {
          "code": "J1560",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 494.16,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 494.16,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 494.16,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 494.16,
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        }
      ]
    },
    {
      "description": "Factor viii recomb novoeight",
      "code_information": [
        {
          "code": "J7182",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 1.43,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 1.43,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 1.43,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 1.43,
          "maximum": 1.43
        }
      ]
    },
    {
      "description": "Inj, factor x, (human), 1iu",
      "code_information": [
        {
          "code": "J7175",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 9.53,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "standard_charge_percentage": 100,
              "estimated_amount": 9.53,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "standard_charge_percentage": 100,
              "estimated_amount": 9.53,
              "methodology": "fee schedule"
            }
          ],
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      ]
    },
    {
      "description": "Inj., bendeka 1 mg",
      "code_information": [
        {
          "code": "J9034",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 13.45,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 13.45,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 13.45,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 13.45,
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        }
      ]
    },
    {
      "description": "Immune globulin, powder",
      "code_information": [
        {
          "code": "J1566",
          "type": "HCPCS"
        },
        {
          "code": "00944-2656-03",
          "type": "NDC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 81.43,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 81.43,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 81.43,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 81.43,
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      ],
      "drug_information": {
        "unit": "1",
        "type": "EA"
      }
    },
    {
      "description": "I&d abscess simple/single",
      "code_information": [
        {
          "code": "10060",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 100.86,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "standard_charge_percentage": 100,
              "estimated_amount": 100.86,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "standard_charge_percentage": 100,
              "estimated_amount": 100.86,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "standard_charge_percentage": 100,
              "estimated_amount": 100.86,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 100.86,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 100.86,
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      ]
    },
    {
      "description": "I&d abscess comp/multiple",
      "code_information": [
        {
          "code": "10061",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 174.96,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "standard_charge_percentage": 100,
              "estimated_amount": 174.96,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 174.96,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "standard_charge_percentage": 100,
              "estimated_amount": 174.96,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
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              "standard_charge_percentage": 100,
              "estimated_amount": 174.96,
              "methodology": "fee schedule"
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          ],
          "minimum": 174.96,
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      ]
    },
    {
      "description": "Intmd rpr s/a/t/ext 2.6-7.5",
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        {
          "code": "12032",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 179.38,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "standard_charge_percentage": 100,
              "estimated_amount": 179.38,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 179.38,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 179.38,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
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              "estimated_amount": 179.38,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 179.38,
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      ]
    },
    {
      "description": "Tis trnfr trunk 10 sq cm/<",
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        {
          "code": "14000",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 477.58,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "standard_charge_percentage": 100,
              "estimated_amount": 477.58,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 477.58,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 477.58,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
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              "standard_charge_percentage": 100,
              "estimated_amount": 477.58,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 477.58,
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      ]
    },
    {
      "description": "Tis trnfr s/a/l 10 sq cm/<",
      "code_information": [
        {
          "code": "14020",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 536.16,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "standard_charge_percentage": 100,
              "estimated_amount": 536.16,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 536.16,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 536.16,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 536.16,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 536.16,
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      ]
    },
    {
      "description": "Fna bx w/us gdn 1st les",
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        {
          "code": "10005",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 69.14,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "standard_charge_percentage": 100,
              "estimated_amount": 69.14,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 69.14,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 69.14,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
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              "estimated_amount": 69.14,
              "methodology": "fee schedule"
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          ],
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      ]
    },
    {
      "description": "Grfg autol fat lipo 50 cc/<",
      "code_information": [
        {
          "code": "15771",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 485.73,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 485.73,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 485.73,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 485.73,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 485.73,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 485.73,
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      ]
    },
    {
      "description": "Core ndl bx lng/med perq",
      "code_information": [
        {
          "code": "32408",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 143.14,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 143.14,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 143.14,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 143.14,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 143.14,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 143.14,
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      ]
    },
    {
      "description": "Needle biopsy lymph nodes",
      "code_information": [
        {
          "code": "38505",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 80.7,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 80.7,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 80.7,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 80.7,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
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              "standard_charge_percentage": 100,
              "estimated_amount": 80.7,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 80.7,
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      ]
    },
    {
      "description": "Needle biopsy of liver",
      "code_information": [
        {
          "code": "47000",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 82.37,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "standard_charge_percentage": 100,
              "estimated_amount": 82.37,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 82.37,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "standard_charge_percentage": 100,
              "estimated_amount": 82.37,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
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              "estimated_amount": 82.37,
              "methodology": "fee schedule"
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          ],
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      ]
    },
    {
      "description": "Exc tr-ext b9+marg >4.0 cm",
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        {
          "code": "11406",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 236.22,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 236.22,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 236.22,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 236.22,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 236.22,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 236.22,
          "maximum": 236.22
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      ]
    },
    {
      "description": "Exc h-f-nk-sp b9+marg 1.1-2",
      "code_information": [
        {
          "code": "11422",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 128.86,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 128.86,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 128.86,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 128.86,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
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              "standard_charge_percentage": 100,
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    },
    {
      "description": "Bx breast 1st lesion strtctc",
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        {
          "code": "19081",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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              "estimated_amount": 153.44,
              "methodology": "fee schedule"
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Regence Blue Cross Blue Shield",
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    {
      "description": "Bx breast 1st lesion us imag",
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        {
          "code": "19083",
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      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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              "estimated_amount": 145.09,
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            },
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Regence Blue Cross Blue Shield",
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    {
      "description": "Bone biopsy trocar/ndl deep",
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        {
          "code": "20225",
          "type": "HCPCS"
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      ],
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        {
          "setting": "outpatient",
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              "payer_name": "SelectHealth Benefit Assurance Company",
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              "estimated_amount": 121.66,
              "methodology": "fee schedule"
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              "estimated_amount": 121.66,
              "methodology": "fee schedule"
            },
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              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 121.66,
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Regence Blue Cross Blue Shield",
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      "description": "Exc back les sc 3 cm/>",
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        {
          "code": "21931",
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        }
      ],
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        {
          "setting": "outpatient",
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              "payer_name": "SelectHealth Benefit Assurance Company",
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              "estimated_amount": 449.57,
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            },
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              "payer_name": "Humana Insurance Company",
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            },
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Regence Blue Cross Blue Shield",
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    {
      "description": "Apply long arm splint",
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        {
          "code": "29105",
          "type": "HCPCS"
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      ],
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          "setting": "outpatient",
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            {
              "payer_name": "Corvel Healthcare Corporation",
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              "methodology": "percent of total billed charges"
            },
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            },
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            },
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            },
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Regence Blue Cross Blue Shield",
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    {
      "description": "Application long leg splint",
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        {
          "code": "29505",
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      ],
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        {
          "setting": "outpatient",
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              "payer_name": "Corvel Healthcare Corporation",
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              "methodology": "percent of total billed charges"
            },
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            {
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            },
            {
              "payer_name": "Humana Insurance Company",
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            },
            {
              "payer_name": "Humana Insurance Company",
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              "payer_name": "Regence Blue Cross Blue Shield",
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    },
    {
      "description": "Application lower leg splint",
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        {
          "code": "29515",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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              "payer_name": "Corvel Healthcare Corporation",
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            },
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              "payer_name": "SelectHealth Benefit Assurance Company",
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Regence Blue Cross Blue Shield",
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    {
      "description": "Strapping of ankle and/or ft",
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        {
          "code": "29540",
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        }
      ],
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        {
          "setting": "outpatient",
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              "payer_name": "Corvel Healthcare Corporation",
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    {
      "description": "Application of paste boot",
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      ],
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        {
          "setting": "outpatient",
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              "payer_name": "Corvel Healthcare Corporation",
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          ],
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    {
      "description": "Windowing of cast",
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        {
          "code": "29730",
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      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Corvel Healthcare Corporation",
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    {
      "description": "Removal of implant deep",
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          "setting": "outpatient",
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              "payer_name": "SelectHealth Benefit Assurance Company",
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Regence Blue Cross Blue Shield",
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    {
      "description": "Exc face tum deep 2 cm/>",
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          "code": "21014",
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        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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              "methodology": "fee schedule"
            },
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              "payer_name": "Humana Insurance Company",
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            },
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              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
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    {
      "description": "Exc neck les sc 3 cm/>",
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        {
          "code": "21552",
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        }
      ],
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        {
          "setting": "outpatient",
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              "payer_name": "SelectHealth Benefit Assurance Company",
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              "estimated_amount": 427.95,
              "methodology": "fee schedule"
            },
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              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
            },
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              "payer_name": "Humana Insurance Company",
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            },
            {
              "payer_name": "Humana Insurance Company",
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            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
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    {
      "description": "Dx bone marrow bx & aspir",
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        {
          "code": "38222",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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              "payer_name": "SelectHealth Benefit Assurance Company",
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              "methodology": "fee schedule"
            },
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              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
            },
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              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
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          ],
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    {
      "description": "Removal of breast lesion",
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        {
          "code": "19120",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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              "payer_name": "SelectHealth Benefit Assurance Company",
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              "methodology": "fee schedule"
            },
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              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
            },
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
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              "methodology": "fee schedule"
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          ],
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    },
    {
      "description": "Partial mastectomy",
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        {
          "code": "19301",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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              "payer_name": "SelectHealth Benefit Assurance Company",
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              "methodology": "fee schedule"
            },
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              "methodology": "fee schedule"
            },
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 630.38,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
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              "methodology": "fee schedule"
            }
          ],
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    },
    {
      "description": "Biopsy/removal lymph nodes",
      "code_information": [
        {
          "code": "38500",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
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              "payer_name": "SelectHealth Benefit Assurance Company",
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              "methodology": "fee schedule"
            },
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              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 243.26,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 243.26,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
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              "standard_charge_percentage": 100,
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      "description": "Biopsy/removal lymph nodes",
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          "code": "38525",
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      "description": "P-mastectomy w/ln removal",
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      "description": "Mast simple complete",
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      "description": "Sho arthrs dx +- synovial bx",
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              "payer_name": "Regence Blue Cross Blue Shield",
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      "description": "Sho arthrs srg lmtd dbrdmt",
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    {
      "description": "Knee arthroscopy/surgery",
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      ],
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 538.42,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 538.42,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 538.42,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 538.42,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 538.42,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 538.42,
          "maximum": 538.42
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      ]
    },
    {
      "description": "Knee arthroscopy/surgery",
      "code_information": [
        {
          "code": "29881",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 518.71,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 518.71,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 518.71,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 518.71,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 518.71,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 518.71,
          "maximum": 518.71
        }
      ]
    },
    {
      "description": "Perq vertebral augmentation",
      "code_information": [
        {
          "code": "22513",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 483.16,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 483.16,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 483.16,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 483.16,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 483.16,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 483.16,
          "maximum": 483.16
        }
      ]
    },
    {
      "description": "Perq vertebral augmentation",
      "code_information": [
        {
          "code": "22514",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 450.27,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 450.27,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 450.27,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 450.27,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 450.27,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 450.27,
          "maximum": 450.27
        }
      ]
    },
    {
      "description": "Revision of unstable kneecap",
      "code_information": [
        {
          "code": "27422",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 710.6,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 710.6,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 710.6,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 710.6,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 710.6,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 710.6,
          "maximum": 710.6
        }
      ]
    },
    {
      "description": "Reconstruction knee",
      "code_information": [
        {
          "code": "27427",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 678.87,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 678.87,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 678.87,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 678.87,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 678.87,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 678.87,
          "maximum": 678.87
        }
      ]
    },
    {
      "description": "Treat kneecap fracture",
      "code_information": [
        {
          "code": "27524",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 721.02,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 721.02,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 721.02,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 721.02,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 721.02,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 721.02,
          "maximum": 721.02
        }
      ]
    },
    {
      "description": "Repair rotator cuff chronic",
      "code_information": [
        {
          "code": "23412",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 814.46,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 814.46,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 814.46,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 814.46,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 814.46,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 814.46,
          "maximum": 814.46
        }
      ]
    },
    {
      "description": "Optx clavicular fx w/int fix",
      "code_information": [
        {
          "code": "23515",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 690.21,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 690.21,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 690.21,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 690.21,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 690.21,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 690.21,
          "maximum": 690.21
        }
      ]
    },
    {
      "description": "Reconstruct elbow lat ligmnt",
      "code_information": [
        {
          "code": "24344",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 1055.01,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 1055.01,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 1055.01,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 1055.01,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 1055.01,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 1055.01,
          "maximum": 1055.01
        }
      ]
    },
    {
      "description": "Treat elbow dislocation",
      "code_information": [
        {
          "code": "24615",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 683.84,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 683.84,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 683.84,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 683.84,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 683.84,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 683.84,
          "maximum": 683.84
        }
      ]
    },
    {
      "description": "Treat ulnar fracture",
      "code_information": [
        {
          "code": "24685",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 627.48,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 627.48,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 627.48,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 627.48,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 627.48,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 627.48,
          "maximum": 627.48
        }
      ]
    },
    {
      "description": "Treat fx rad extra-articul",
      "code_information": [
        {
          "code": "25607",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 710.74,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 710.74,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 710.74,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 710.74,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 710.74,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 710.74,
          "maximum": 710.74
        }
      ]
    },
    {
      "description": "Treat fx rad intra-articul",
      "code_information": [
        {
          "code": "25608",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 793.89,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 793.89,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 793.89,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 793.89,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 793.89,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 793.89,
          "maximum": 793.89
        }
      ]
    },
    {
      "description": "Treat fracture ulnar styloid",
      "code_information": [
        {
          "code": "25652",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 599.47,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 599.47,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 599.47,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 599.47,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 599.47,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 599.47,
          "maximum": 599.47
        }
      ]
    },
    {
      "description": "Sho arthrs srg rt8tr cuf rpr",
      "code_information": [
        {
          "code": "29827",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 1018.42,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 1018.42,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 1018.42,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 1018.42,
              "methodology": "fee schedule"
            },
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      "description": "Sho arthrs srg bicp tenodsis",
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        {
          "code": "29828",
          "type": "HCPCS"
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      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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      "description": "Repair of humerus",
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        {
          "code": "24430",
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      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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    {
      "description": "Total hip arthroplasty",
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        {
          "code": "27130",
          "type": "HCPCS"
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      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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    {
      "description": "Revision of knee joint",
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        {
          "code": "27446",
          "type": "HCPCS"
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      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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              "methodology": "fee schedule"
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              "methodology": "fee schedule"
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              "methodology": "fee schedule"
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    {
      "description": "Total knee arthroplasty",
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        {
          "code": "27447",
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      ],
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        {
          "setting": "outpatient",
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              "payer_name": "SelectHealth Benefit Assurance Company",
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      "description": "Treat/graft heel fracture",
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        {
          "code": "28420",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
          "payers_information": [
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              "payer_name": "SelectHealth Benefit Assurance Company",
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    {
      "description": "Nasal endoscopy dx",
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        {
          "code": "31231",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "Corvel Healthcare Corporation",
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              "estimated_amount": 467.5,
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    {
      "description": "Nsl/sins ndsc surg bx polypc",
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        {
          "code": "31237",
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        {
          "setting": "outpatient",
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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              "methodology": "fee schedule"
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              "payer_name": "Regence Blue Cross Blue Shield",
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      "description": "Dx bronchoscope/wash",
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        {
          "code": "31622",
          "type": "HCPCS"
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Corvel Healthcare Corporation",
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    {
      "description": "Treat humerus fracture",
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        {
          "code": "24516",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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            {
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              "estimated_amount": 820.85,
              "methodology": "fee schedule"
            },
            {
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              "methodology": "fee schedule"
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              "payer_name": "Regence Blue Cross Blue Shield",
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    {
      "description": "Ablate inf turbinate superf",
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        {
          "code": "30801",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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              "methodology": "fee schedule"
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            },
            {
              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
            },
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              "payer_name": "Regence Blue Cross Blue Shield",
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    {
      "description": "Exploration maxillary sinus",
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        {
          "code": "31256",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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              "estimated_amount": 170.7,
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            {
              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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            {
              "payer_name": "Regence Blue Cross Blue Shield",
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    {
      "description": "Nsl/sins ndsc w/prtl ethmdct",
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        {
          "code": "31254",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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              "estimated_amount": 230.62,
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            },
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 230.62,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 230.62,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 230.62,
              "methodology": "fee schedule"
            },
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              "payer_name": "Regence Blue Cross Blue Shield",
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    {
      "description": "Nsl/sins ndsc tot w/sphendt",
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        {
          "code": "31257",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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              "estimated_amount": 422.86,
              "methodology": "fee schedule"
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              "estimated_amount": 422.86,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 422.86,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "standard_charge_percentage": 100,
              "estimated_amount": 422.86,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
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    {
      "description": "Nsl/sins ndsc sphn tiss rmvl",
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        {
          "code": "31259",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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              "estimated_amount": 446.8,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "standard_charge_percentage": 100,
              "estimated_amount": 446.8,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 446.8,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 446.8,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 446.8,
              "methodology": "fee schedule"
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    {
      "description": "Endoscopy maxillary sinus",
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        {
          "code": "31267",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
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              "estimated_amount": 251.98,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 251.98,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 251.98,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 251.98,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 251.98,
              "methodology": "fee schedule"
            }
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          "maximum": 251.98
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    {
      "description": "Nsl/sins ndsc frnt tiss rmvl",
      "code_information": [
        {
          "code": "31276",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 358.76,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 358.76,
              "methodology": "fee schedule"
            },
            {
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              "plan_name": "Medicare Advantage HMO",
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              "estimated_amount": 358.76,
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            },
            {
              "payer_name": "Humana Insurance Company",
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              "payer_name": "Regence Blue Cross Blue Shield",
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    {
      "description": "Nasal/sinus endoscopy surg",
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        {
          "code": "31288",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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      "description": "Insert emergency airway",
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        {
          "code": "31500",
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      ],
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        {
          "setting": "outpatient",
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              "methodology": "percent of total billed charges"
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      "description": "Change of windpipe airway",
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        {
          "code": "31502",
          "type": "HCPCS"
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      ],
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        {
          "setting": "outpatient",
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              "payer_name": "Corvel Healthcare Corporation",
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      "description": "Remove tonsils and adenoids",
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        {
          "code": "42821",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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        {
          "code": "42826",
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      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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      "description": "Excise inferior turbinate",
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        {
          "code": "30130",
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        }
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        {
          "setting": "outpatient",
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      "description": "Resect inferior turbinate",
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      ],
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          "setting": "outpatient",
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              "payer_name": "SelectHealth Benefit Assurance Company",
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    {
      "description": "Repair of nasal septum",
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        {
          "code": "30520",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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              "payer_name": "SelectHealth Benefit Assurance Company",
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    {
      "description": "Insj picc 5 yr+ w/o imaging",
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        {
          "code": "36569",
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      ],
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        {
          "setting": "outpatient",
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              "payer_name": "Regence Blue Cross Blue Shield",
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    {
      "description": "Insj picc rs&i 5 yr+",
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        {
          "code": "36573",
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        }
      ],
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        {
          "setting": "outpatient",
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              "payer_name": "SelectHealth Benefit Assurance Company",
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            },
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    {
      "description": "Removal tunneled cv cath",
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        {
          "code": "36590",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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            },
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            },
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            },
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Regence Blue Cross Blue Shield",
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          ],
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    {
      "description": "Reposition venous catheter",
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        {
          "code": "36597",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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    {
      "description": "Intro cath dialysis circuit",
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        {
          "code": "36901",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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              "payer_name": "SelectHealth Benefit Assurance Company",
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      "description": "Vein x-ray arms/legs",
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        {
          "code": "75822",
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        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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      "description": "Insert non-tunnel cv cath",
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        {
          "code": "36556",
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        }
      ],
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        {
          "setting": "outpatient",
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              "payer_name": "Regence Blue Cross Blue Shield",
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    {
      "description": "Insert tunneled cv cath",
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          "code": "36558",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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            },
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              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 242.93,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 242.93,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 242.93,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 242.93,
          "maximum": 242.93
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      ]
    },
    {
      "description": "Insert tunneled cv cath",
      "code_information": [
        {
          "code": "36561",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 312.1,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 312.1,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 312.1,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 312.1,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
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              "standard_charge_percentage": 100,
              "estimated_amount": 312.1,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 312.1,
          "maximum": 312.1
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      ]
    },
    {
      "description": "Av fusion direct any site",
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        {
          "code": "36821",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 618.03,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 618.03,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 618.03,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 618.03,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 618.03,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 618.03,
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      ]
    },
    {
      "description": "Rem endovas vena cava filter",
      "code_information": [
        {
          "code": "37193",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 323.64,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 323.64,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 323.64,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 323.64,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 323.64,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 323.64,
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      ]
    },
    {
      "description": "Phleb veins - extrem 20+",
      "code_information": [
        {
          "code": "37766",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 311.71,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 311.71,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 311.71,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 311.71,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
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              "estimated_amount": 311.71,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 311.71,
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      ]
    },
    {
      "description": "Remove tunneled ip cath",
      "code_information": [
        {
          "code": "49422",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 209.64,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "standard_charge_percentage": 100,
              "estimated_amount": 209.64,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 209.64,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 209.64,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 209.64,
              "methodology": "fee schedule"
            }
          ],
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      ]
    },
    {
      "description": "Aspirate pleura w/ imaging",
      "code_information": [
        {
          "code": "32555",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 102.67,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "standard_charge_percentage": 100,
              "estimated_amount": 102.67,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 102.67,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 102.67,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 102.67,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 102.67,
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      ]
    },
    {
      "description": "Removal tunneled cv cath",
      "code_information": [
        {
          "code": "36589",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 127.98,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 127.98,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 127.98,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 127.98,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 127.98,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 127.98,
          "maximum": 127.98
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      ]
    },
    {
      "description": "Coronary artery angio s&i",
      "code_information": [
        {
          "code": "93454",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 824.78,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "standard_charge_percentage": 100,
              "estimated_amount": 824.78,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 824.78,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 824.78,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 824.78,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 824.78,
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    },
    {
      "description": "L hrt artery/ventricle angio",
      "code_information": [
        {
          "code": "93458",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
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              "estimated_amount": 949.65,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 949.65,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 949.65,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
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              "estimated_amount": 949.65,
              "methodology": "fee schedule"
            }
          ],
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      ]
    },
    {
      "description": "L hrt art/grft angio",
      "code_information": [
        {
          "code": "93459",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 1022.34,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "standard_charge_percentage": 100,
              "estimated_amount": 1022.34,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 1022.34,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "standard_charge_percentage": 100,
              "estimated_amount": 1022.34,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
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              "standard_charge_percentage": 100,
              "estimated_amount": 1022.34,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 1022.34,
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      ]
    },
    {
      "description": "R&l hrt art/ventricle angio",
      "code_information": [
        {
          "code": "93460",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 1134.31,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 1134.31,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 1134.31,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 1134.31,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 1134.31,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 1134.31,
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      ]
    },
    {
      "description": "Intro cath dialysis circuit",
      "code_information": [
        {
          "code": "36902",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 224,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 224,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 224,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 224,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 224,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 224,
          "maximum": 224
        }
      ]
    },
    {
      "description": "Fem/popl revas w/tla",
      "code_information": [
        {
          "code": "37224",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 414.3,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 414.3,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 414.3,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 414.3,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 414.3,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 414.3,
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      ]
    },
    {
      "description": "Trluml balo angiop 1st art",
      "code_information": [
        {
          "code": "37246",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 324.96,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 324.96,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 324.96,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 324.96,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 324.96,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 324.96,
          "maximum": 324.96
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      ]
    },
    {
      "description": "Intro cath dialysis circuit",
      "code_information": [
        {
          "code": "36903",
          "type": "HCPCS"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
              "plan_name": "SelectHealth Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 294.6,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PPO",
              "standard_charge_percentage": 100,
              "estimated_amount": 294.6,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage HMO",
              "standard_charge_percentage": 100,
              "estimated_amount": 294.6,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
              "plan_name": "Medicare Advantage PFFS",
              "standard_charge_percentage": 100,
              "estimated_amount": 294.6,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Regence Blue Cross Blue Shield",
              "plan_name": "Medicare Advantage",
              "standard_charge_percentage": 100,
              "estimated_amount": 294.6,
              "methodology": "fee schedule"
            }
          ],
          "minimum": 294.6,
          "maximum": 294.6
        }
      ]
    },
    {
      "description": "Thrmbc/nfs dialysis circuit",
      "code_information": [
        {
          "code": "36905",
          "type": "HCPCS"
        }
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        {
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      "description": "Tib/per revasc w/tla",
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        {
          "code": "37228",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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    {
      "description": "Open/perq place stent same",
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        {
          "code": "37238",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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              "estimated_amount": 286.2,
              "methodology": "fee schedule"
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      "description": "Vasc embolize/occlude organ",
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        {
          "code": "37243",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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              "payer_name": "SelectHealth Benefit Assurance Company",
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      "description": "Prq card stent w/angio 1 vsl",
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        {
          "code": "92928",
          "type": "HCPCS"
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        {
          "setting": "outpatient",
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              "payer_name": "SelectHealth Benefit Assurance Company",
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      "description": "Thrmbc/nfs dialysis circuit",
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        {
          "code": "36906",
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        }
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        {
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      "description": "Fem/popl revas w/ather",
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        {
          "code": "37225",
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      ],
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    {
      "description": "Tib/per revasc w/ather",
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          "code": "37229",
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              "payer_name": "SelectHealth Benefit Assurance Company",
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    {
      "description": "Av fuse uppr arm basilic",
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        {
          "code": "36819",
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      "description": "Artery-vein nonautograft",
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        {
          "code": "36830",
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        }
      ],
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        {
          "setting": "outpatient",
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              "payer_name": "SelectHealth Benefit Assurance Company",
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    {
      "description": "Av fistula revision open",
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        {
          "code": "36832",
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      ],
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        {
          "setting": "outpatient",
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              "payer_name": "SelectHealth Benefit Assurance Company",
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              "payer_name": "Regence Blue Cross Blue Shield",
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      "description": "Thrombolytic art therapy",
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        {
          "code": "37211",
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      ],
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        {
          "setting": "outpatient",
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      "description": "Remove&replace pm gen singl",
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        {
          "code": "33227",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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              "payer_name": "SelectHealth Benefit Assurance Company",
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              "payer_name": "Regence Blue Cross Blue Shield",
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    {
      "description": "Insert heart pm ventricular",
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        {
          "code": "33207",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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              "payer_name": "SelectHealth Benefit Assurance Company",
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      "description": "Remv&replc pm gen dual lead",
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        {
          "code": "33228",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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            },
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            },
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              "payer_name": "Regence Blue Cross Blue Shield",
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      "description": "Transfusion bld/bld compnt",
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        {
          "code": "36430",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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            },
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      "description": "Apheresis plasma",
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        {
          "code": "36514",
          "type": "HCPCS"
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      ],
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          "setting": "outpatient",
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      "description": "Egd diagnostic brush wash",
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        {
          "code": "43235",
          "type": "HCPCS"
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      ],
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        {
          "setting": "outpatient",
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              "methodology": "percent of total billed charges"
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    {
      "description": "Egd biopsy single/multiple",
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        {
          "code": "43239",
          "type": "HCPCS"
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      ],
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        {
          "setting": "outpatient",
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              "estimated_amount": 130.36,
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    {
      "description": "Egd varices ligation",
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        {
          "code": "43244",
          "type": "HCPCS"
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      ],
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        {
          "setting": "outpatient",
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            {
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              "estimated_amount": 230,
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    {
      "description": "Egd place gastrostomy tube",
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        {
          "code": "43246",
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      ],
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        {
          "setting": "outpatient",
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            },
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    {
      "description": "Proctosigmoidoscopy dx",
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        {
          "code": "45300",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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            {
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    {
      "description": "Abd paracentesis w/imaging",
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        {
          "code": "49083",
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        }
      ],
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        {
          "setting": "outpatient",
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              "payer_name": "SelectHealth Benefit Assurance Company",
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              "estimated_amount": 99.61,
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    {
      "description": "Peritoneal lavage",
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        {
          "code": "49084",
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      ],
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        {
          "setting": "outpatient",
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              "payer_name": "Corvel Healthcare Corporation",
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      "description": "Colonoscopy and biopsy",
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        {
          "code": "45380",
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      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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      "description": "Colonoscopy submucous njx",
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          "code": "45381",
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        }
      ],
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        {
          "setting": "outpatient",
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            },
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            },
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    {
      "description": "Colonoscopy w/lesion removal",
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        {
          "code": "45385",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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              "payer_name": "SelectHealth Benefit Assurance Company",
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    {
      "description": "Colonoscopy w/ablation",
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        {
          "code": "45388",
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        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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    {
      "description": "Diagnostic anoscopy & biopsy",
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        {
          "code": "46607",
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        }
      ],
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          "setting": "outpatient",
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    {
      "description": "Remove int/ext hem 1 group",
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          "code": "46255",
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            },
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            },
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      "description": "Remove in/ex hem groups 2+",
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          "code": "46260",
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      ],
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        {
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              "payer_name": "SelectHealth Benefit Assurance Company",
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            },
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            },
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            },
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    {
      "description": "Diagnostic colonoscopy",
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        {
          "code": "45378",
          "type": "HCPCS"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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            },
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            },
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              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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      "description": "Prp i/hern init reduc >5 yr",
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          "code": "49505",
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      ],
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        {
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        {
          "code": "49507",
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      ],
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        {
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        {
          "code": "49520",
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        {
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      "description": "Rpr aa hrn 1st < 3 cm rdc",
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        {
          "code": "49591",
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        {
          "setting": "outpatient",
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      "description": "Removal of hydrocele",
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        {
          "code": "55040",
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          "code": "38570",
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        {
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        {
          "code": "47562",
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        {
          "setting": "outpatient",
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          "code": "47563",
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      ],
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        {
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          "code": "49322",
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      "description": "Destruction anal lesion(s)",
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          "code": "46924",
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        {
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      "description": "Partial removal of thyroid",
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        {
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      ],
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      "description": "Laparoscopy lymphadenectomy",
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        {
          "code": "38571",
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        }
      ],
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        {
          "setting": "outpatient",
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        {
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      "description": "Laparo-vag hyst w/t/o compl",
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          "code": "58554",
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        }
      ],
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        {
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    {
      "description": "Tlh uterus 250 g or less",
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          "code": "58570",
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        }
      ],
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        {
          "setting": "outpatient",
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              "estimated_amount": 772.66,
              "methodology": "fee schedule"
            },
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              "methodology": "fee schedule"
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              "payer_name": "Regence Blue Cross Blue Shield",
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    },
    {
      "description": "Tlh w/t/o 250 g or less",
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        {
          "code": "58571",
          "type": "HCPCS"
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      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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    {
      "description": "Reposition gastrostomy tube",
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        {
          "code": "43761",
          "type": "HCPCS"
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      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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              "estimated_amount": 98.74,
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      "description": "Rplc gtube no revj trc",
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        {
          "code": "43762",
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      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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      "description": "Rpr aa hrn 1st < 3 ncr/strn",
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        {
          "code": "49592",
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      ],
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        {
          "setting": "outpatient",
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            {
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          "code": "49594",
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        {
          "setting": "outpatient",
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            {
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      "description": "Lap ing hernia repair init",
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        {
          "setting": "outpatient",
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    {
      "description": "Lap ing hernia repair recur",
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        {
          "code": "49651",
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        {
          "setting": "outpatient",
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      "description": "Laparo-asst vag hysterectomy",
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          "code": "58550",
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        {
          "setting": "outpatient",
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      "description": "Laparoscopy remove adnexa",
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          "code": "58661",
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        {
          "setting": "outpatient",
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            {
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      "description": "Laparoscopy excise lesions",
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        {
          "code": "58662",
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      ],
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        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Regence Blue Cross Blue Shield",
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      "description": "Cystoscopy and treatment",
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        {
          "code": "52310",
          "type": "HCPCS"
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      ],
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        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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            {
              "payer_name": "Humana Insurance Company",
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              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 142.9,
              "methodology": "fee schedule"
            },
            {
              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 142.9,
              "methodology": "fee schedule"
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              "payer_name": "Regence Blue Cross Blue Shield",
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    {
      "description": "Circum 28 days or older",
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        {
          "code": "54161",
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      ],
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        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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              "estimated_amount": 187.93,
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Humana Insurance Company",
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              "estimated_amount": 187.93,
              "methodology": "fee schedule"
            },
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              "estimated_amount": 187.93,
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              "payer_name": "Regence Blue Cross Blue Shield",
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    {
      "description": "Biopsy of prostate",
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        {
          "code": "55700",
          "type": "HCPCS"
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      ],
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        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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              "methodology": "fee schedule"
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              "payer_name": "Humana Insurance Company",
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              "methodology": "fee schedule"
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      "description": "Fragmenting of kidney stone",
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          "code": "50590",
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        {
          "setting": "outpatient",
          "payers_information": [
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              "payer_name": "SelectHealth Benefit Assurance Company",
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              "methodology": "fee schedule"
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Humana Insurance Company",
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              "payer_name": "Regence Blue Cross Blue Shield",
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      "description": "Cystoscopy and treatment",
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          "code": "52224",
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        }
      ],
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        {
          "setting": "outpatient",
          "payers_information": [
            {
              "payer_name": "SelectHealth Benefit Assurance Company",
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              "payer_name": "Humana Insurance Company",
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            },
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            },
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