{ "hospital_name": "Palos Community Hospital", "last_updated_on": "2026-04-01", "version": "3.0.0", "location_name": [ "Northwestern Medicine Palos Hospital" ], "hospital_address": [ "12251 S. 80th Ave., Palos Heights, IL 60463" ], "license_information": { "license_number": "0003210", "state": "IL" }, "attestation": { "attestation": "To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.", "confirm_attestation": true, "attester_name": "John Orsini" }, "type_2_npi": [ "1043600026", "1184699118", "1851386692" ], "standard_charge_information": [ { "description": "2.4MM VA-LCP VOLAR RIM DSTL RAD PLT 6H HD 5H SHAFT RT", "code_information": [ { "code": "SUP-377023", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 357.8, "maximum": 2236.25, "setting": "outpatient", "gross_charge": 2236.25, "discounted_cash": 1565.37, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1142.72, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 252.68, "10th_percentile": 252.68, "90th_percentile": 252.68, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 480.79, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 373.87, "10th_percentile": 373.87, "90th_percentile": 373.87, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 357.8, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 357.8, "10th_percentile": 357.8, "90th_percentile": 357.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 357.8, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 357.8, "10th_percentile": 357.8, "90th_percentile": 357.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 357.8, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 357.8, "10th_percentile": 357.8, "90th_percentile": 357.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 429.36, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 429.36, "10th_percentile": 429.36, "90th_percentile": 429.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 429.36, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 429.36, "10th_percentile": 429.36, "90th_percentile": 429.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1270.19, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1270.19, "10th_percentile": 1270.19, "90th_percentile": 1270.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1270.19, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1270.19, "10th_percentile": 1270.19, "90th_percentile": 1270.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 875.04, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 875.04, "10th_percentile": 875.04, "90th_percentile": 875.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 875.04, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 875.04, "10th_percentile": 875.04, "90th_percentile": 875.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 661.93, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.51, "10th_percentile": 5.51, "90th_percentile": 5.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1677.19, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1677.19, "10th_percentile": 1677.19, "90th_percentile": 1677.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1789.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1789.0, "10th_percentile": 1789.0, "90th_percentile": 1789.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1436.34, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1436.34, "10th_percentile": 1436.34, "90th_percentile": 1436.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2236.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,236.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2236.25, "10th_percentile": 2236.25, "90th_percentile": 2236.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,236.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1118.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1118.13, "10th_percentile": 1118.13, "90th_percentile": 1118.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1789.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1789.0, "10th_percentile": 1789.0, "90th_percentile": 1789.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 1013.02, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1013.02, "10th_percentile": 1013.02, "90th_percentile": 1013.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1118.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1118.13, "10th_percentile": 1118.13, "90th_percentile": 1118.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1900.81, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1900.81, "10th_percentile": 1900.81, "90th_percentile": 1900.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1565.38, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1565.38, "10th_percentile": 1565.38, "90th_percentile": 1565.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 758.09, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 758.09, "10th_percentile": 758.09, "90th_percentile": 758.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2236.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2236.25, "10th_percentile": 2236.25, "90th_percentile": 2236.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1341.75, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1341.75, "10th_percentile": 1341.75, "90th_percentile": 1341.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1677.19, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1677.19, "10th_percentile": 1677.19, "90th_percentile": 1677.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 418.18, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 418.18, "10th_percentile": 418.18, "90th_percentile": 418.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2236.25, "10th_percentile": 2236.25, "90th_percentile": 2236.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2236.25, "10th_percentile": 2236.25, "90th_percentile": 2236.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2236.25, "10th_percentile": 2236.25, "90th_percentile": 2236.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2236.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2236.25, "10th_percentile": 2236.25, "90th_percentile": 2236.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2236.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2236.25, "10th_percentile": 2236.25, "90th_percentile": 2236.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2236.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2236.25, "10th_percentile": 2236.25, "90th_percentile": 2236.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2236.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2236.25, "10th_percentile": 2236.25, "90th_percentile": 2236.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2236.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2236.25, "10th_percentile": 2236.25, "90th_percentile": 2236.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2236.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2236.25, "10th_percentile": 2236.25, "90th_percentile": 2236.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2236.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2236.25, "10th_percentile": 2236.25, "90th_percentile": 2236.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2236.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2236.25, "10th_percentile": 2236.25, "90th_percentile": 2236.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "21GA X 15CM NEEDLE PERC ENTRY ECHOTP W/O BASEPLT", "code_information": [ { "code": "SUP-150868", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 0.97, "maximum": 6.92, "setting": "outpatient", "gross_charge": 6.92, "discounted_cash": 4.84, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2.71, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.71, "10th_percentile": 2.71, "90th_percentile": 2.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2.71, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.71, "10th_percentile": 2.71, "90th_percentile": 2.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 3.06, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.06, "10th_percentile": 3.06, "90th_percentile": 3.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 3.06, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.06, "10th_percentile": 3.06, "90th_percentile": 3.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 3.93, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.93, "10th_percentile": 3.93, "90th_percentile": 3.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 3.93, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.93, "10th_percentile": 3.93, "90th_percentile": 3.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 5.19, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 5.19, "10th_percentile": 5.19, "90th_percentile": 5.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 1.49, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 1.49, "10th_percentile": 1.49, "90th_percentile": 1.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 2.35, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 2.35, "10th_percentile": 2.35, "90th_percentile": 2.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 4.84, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 4.84, "10th_percentile": 4.84, "90th_percentile": 4.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 5.19, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 5.19, "10th_percentile": 5.19, "90th_percentile": 5.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 3.46, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.46, "10th_percentile": 3.46, "90th_percentile": 3.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 3.46, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 3.46, "10th_percentile": 3.46, "90th_percentile": 3.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 5.54, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 5.54, "10th_percentile": 5.54, "90th_percentile": 5.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 4.15, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 4.15, "10th_percentile": 4.15, "90th_percentile": 4.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 4.44, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 4.44, "10th_percentile": 4.44, "90th_percentile": 4.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 5.88, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 5.88, "10th_percentile": 5.88, "90th_percentile": 5.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 1.29, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.29, "10th_percentile": 1.29, "90th_percentile": 1.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 5.54, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.54, "10th_percentile": 5.54, "90th_percentile": 5.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 2.05, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.05, "10th_percentile": 2.05, "90th_percentile": 2.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 6.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6.92 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 6.92, "10th_percentile": 6.92, "90th_percentile": 6.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6.92 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.17, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.17, "10th_percentile": 1.17, "90th_percentile": 1.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.97, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.97, "10th_percentile": 0.97, "90th_percentile": 0.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.99, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.99, "10th_percentile": 0.99, "90th_percentile": 0.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 6.92, "10th_percentile": 6.92, "90th_percentile": 6.92, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6.92, "10th_percentile": 6.92, "90th_percentile": 6.92, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6.92, "10th_percentile": 6.92, "90th_percentile": 6.92, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.92, "10th_percentile": 6.92, "90th_percentile": 6.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.92, "10th_percentile": 6.92, "90th_percentile": 6.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.92, "10th_percentile": 6.92, "90th_percentile": 6.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.92, "10th_percentile": 6.92, "90th_percentile": 6.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.92, "10th_percentile": 6.92, "90th_percentile": 6.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.92, "10th_percentile": 6.92, "90th_percentile": 6.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.92, "10th_percentile": 6.92, "90th_percentile": 6.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 6.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 6.92, "10th_percentile": 6.92, "90th_percentile": 6.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 3.13, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.13, "10th_percentile": 3.13, "90th_percentile": 3.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 3.54, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.54, "10th_percentile": 3.54, "90th_percentile": 3.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.92, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.92, "10th_percentile": 6.92, "90th_percentile": 6.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "4.5X15MM PK PAPYRUS COVERED STENT", "code_information": [ { "code": "SUP-350650", "type": "CDM" }, { "code": "C1874", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 1106.83, "maximum": 6917.67, "setting": "outpatient", "gross_charge": 6917.67, "discounted_cash": 4842.37, "payers_information": [ { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 6917.67, "10th_percentile": 6917.67, "90th_percentile": 6917.67, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6917.67, "10th_percentile": 6917.67, "90th_percentile": 6917.67, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6917.67, "10th_percentile": 6917.67, "90th_percentile": 6917.67, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1106.83, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1106.83, "10th_percentile": 1106.83, "90th_percentile": 1106.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1106.83, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1106.83, "10th_percentile": 1106.83, "90th_percentile": 1106.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 1106.83, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1106.83, "10th_percentile": 1106.83, "90th_percentile": 1106.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2706.88, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2706.88, "10th_percentile": 2706.88, "90th_percentile": 2706.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2706.88, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2706.88, "10th_percentile": 2706.88, "90th_percentile": 2706.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 3929.24, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3929.24, "10th_percentile": 3929.24, "90th_percentile": 3929.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1328.19, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1328.19, "10th_percentile": 1328.19, "90th_percentile": 1328.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1328.19, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1328.19, "10th_percentile": 1328.19, "90th_percentile": 1328.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 1293.6, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1293.6, "10th_percentile": 1293.6, "90th_percentile": 1293.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 5534.14, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5534.14, "10th_percentile": 5534.14, "90th_percentile": 5534.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 6917.67, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,917.67 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 6917.67, "10th_percentile": 6917.67, "90th_percentile": 6917.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,917.67 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 1487.3, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 1487.3, "10th_percentile": 1487.3, "90th_percentile": 1487.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 5534.14, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 5534.14, "10th_percentile": 5534.14, "90th_percentile": 5534.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 3458.84, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3458.84, "10th_percentile": 3458.84, "90th_percentile": 3458.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 2047.63, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2047.63, "10th_percentile": 2047.63, "90th_percentile": 2047.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 5188.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 5188.25, "10th_percentile": 5188.25, "90th_percentile": 5188.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 5188.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 5188.25, "10th_percentile": 5188.25, "90th_percentile": 5188.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 5880.02, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 5880.02, "10th_percentile": 5880.02, "90th_percentile": 5880.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 3458.84, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 3458.84, "10th_percentile": 3458.84, "90th_percentile": 3458.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 4150.6, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 4150.6, "10th_percentile": 4150.6, "90th_percentile": 4150.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 4842.37, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 4842.37, "10th_percentile": 4842.37, "90th_percentile": 4842.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 4443.22, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 4443.22, "10th_percentile": 4443.22, "90th_percentile": 4443.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 3534.93, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3534.93, "10th_percentile": 3534.93, "90th_percentile": 3534.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 3133.7, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3133.7, "10th_percentile": 3133.7, "90th_percentile": 3133.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 6917.67, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 6917.67, "10th_percentile": 6917.67, "90th_percentile": 6917.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6917.67, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6917.67, "10th_percentile": 6917.67, "90th_percentile": 6917.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6917.67, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6917.67, "10th_percentile": 6917.67, "90th_percentile": 6917.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6917.67, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6917.67, "10th_percentile": 6917.67, "90th_percentile": 6917.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6917.67, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6917.67, "10th_percentile": 6917.67, "90th_percentile": 6917.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6917.67, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6917.67, "10th_percentile": 6917.67, "90th_percentile": 6917.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6917.67, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6917.67, "10th_percentile": 6917.67, "90th_percentile": 6917.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6917.67, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6917.67, "10th_percentile": 6917.67, "90th_percentile": 6917.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6917.67, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6917.67, "10th_percentile": 6917.67, "90th_percentile": 6917.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 2345.09, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 2345.09, "10th_percentile": 2345.09, "90th_percentile": 2345.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 3929.24, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3929.24, "10th_percentile": 3929.24, "90th_percentile": 3929.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "5.5MM X 50MM POLY RELINE SPINAL BONE SCREW", "code_information": [ { "code": "SUP-311408", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 235.71, "maximum": 1473.21, "setting": "outpatient", "gross_charge": 1473.21, "discounted_cash": 1031.25, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 316.74, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 373.87, "10th_percentile": 373.87, "90th_percentile": 373.87, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 836.78, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 836.78, "10th_percentile": 836.78, "90th_percentile": 836.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 499.42, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 499.42, "10th_percentile": 499.42, "90th_percentile": 499.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1473.21, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1473.21, "10th_percentile": 1473.21, "90th_percentile": 1473.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 752.81, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 252.68, "10th_percentile": 252.68, "90th_percentile": 252.68, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 235.71, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 235.71, "10th_percentile": 235.71, "90th_percentile": 235.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 235.71, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 235.71, "10th_percentile": 235.71, "90th_percentile": 235.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 235.71, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 235.71, "10th_percentile": 235.71, "90th_percentile": 235.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 282.86, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 282.86, "10th_percentile": 282.86, "90th_percentile": 282.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 282.86, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 282.86, "10th_percentile": 282.86, "90th_percentile": 282.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 836.78, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 836.78, "10th_percentile": 836.78, "90th_percentile": 836.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 576.47, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 576.47, "10th_percentile": 576.47, "90th_percentile": 576.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 576.47, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 576.47, "10th_percentile": 576.47, "90th_percentile": 576.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 436.07, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.51, "10th_percentile": 5.51, "90th_percentile": 5.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1178.57, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1178.57, "10th_percentile": 1178.57, "90th_percentile": 1178.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1031.25, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1031.25, "10th_percentile": 1031.25, "90th_percentile": 1031.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 275.49, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 275.49, "10th_percentile": 275.49, "90th_percentile": 275.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 736.61, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 736.61, "10th_percentile": 736.61, "90th_percentile": 736.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1473.21, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1473.21, "10th_percentile": 1473.21, "90th_percentile": 1473.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1473.21, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,473.21 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1473.21, "10th_percentile": 1473.21, "90th_percentile": 1473.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,473.21 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1104.91, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1104.91, "10th_percentile": 1104.91, "90th_percentile": 1104.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 883.93, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 883.93, "10th_percentile": 883.93, "90th_percentile": 883.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1104.91, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1104.91, "10th_percentile": 1104.91, "90th_percentile": 1104.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 946.24, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 946.24, "10th_percentile": 946.24, "90th_percentile": 946.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 667.36, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 667.36, "10th_percentile": 667.36, "90th_percentile": 667.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1178.57, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1178.57, "10th_percentile": 1178.57, "90th_percentile": 1178.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 736.61, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 736.61, "10th_percentile": 736.61, "90th_percentile": 736.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1252.23, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1252.23, "10th_percentile": 1252.23, "90th_percentile": 1252.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1473.21, "10th_percentile": 1473.21, "90th_percentile": 1473.21, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1473.21, "10th_percentile": 1473.21, "90th_percentile": 1473.21, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1473.21, "10th_percentile": 1473.21, "90th_percentile": 1473.21, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1473.21, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1473.21, "10th_percentile": 1473.21, "90th_percentile": 1473.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1473.21, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1473.21, "10th_percentile": 1473.21, "90th_percentile": 1473.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1473.21, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1473.21, "10th_percentile": 1473.21, "90th_percentile": 1473.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1473.21, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1473.21, "10th_percentile": 1473.21, "90th_percentile": 1473.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1473.21, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1473.21, "10th_percentile": 1473.21, "90th_percentile": 1473.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1473.21, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1473.21, "10th_percentile": 1473.21, "90th_percentile": 1473.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1473.21, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1473.21, "10th_percentile": 1473.21, "90th_percentile": 1473.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "6.5 HEALIX ADVANCE BR W OCORD", "code_information": [ { "code": "SUP-312486", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 129.13, "maximum": 807.06, "setting": "outpatient", "gross_charge": 807.06, "discounted_cash": 564.94, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 412.41, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 252.68, "10th_percentile": 252.68, "90th_percentile": 252.68, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 458.41, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 458.41, "10th_percentile": 458.41, "90th_percentile": 458.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 518.37, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 518.37, "10th_percentile": 518.37, "90th_percentile": 518.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 365.6, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 365.6, "10th_percentile": 365.6, "90th_percentile": 365.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 403.53, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 403.53, "10th_percentile": 403.53, "90th_percentile": 403.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 686.0, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 686.0, "10th_percentile": 686.0, "90th_percentile": 686.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 564.94, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 564.94, "10th_percentile": 564.94, "90th_percentile": 564.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 807.06, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 807.06, "10th_percentile": 807.06, "90th_percentile": 807.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 484.24, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 484.24, "10th_percentile": 484.24, "90th_percentile": 484.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 605.3, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 605.3, "10th_percentile": 605.3, "90th_percentile": 605.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 807.06, "10th_percentile": 807.06, "90th_percentile": 807.06, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 807.06, "10th_percentile": 807.06, "90th_percentile": 807.06, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 807.06, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 807.06, "10th_percentile": 807.06, "90th_percentile": 807.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 807.06, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 807.06, "10th_percentile": 807.06, "90th_percentile": 807.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 807.06, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 807.06, "10th_percentile": 807.06, "90th_percentile": 807.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 807.06, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 807.06, "10th_percentile": 807.06, "90th_percentile": 807.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 807.06, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 807.06, "10th_percentile": 807.06, "90th_percentile": 807.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 807.06, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 807.06, "10th_percentile": 807.06, "90th_percentile": 807.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 173.52, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 373.87, "10th_percentile": 373.87, "90th_percentile": 373.87, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 129.13, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 129.13, "10th_percentile": 129.13, "90th_percentile": 129.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 129.13, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 129.13, "10th_percentile": 129.13, "90th_percentile": 129.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 129.13, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 129.13, "10th_percentile": 129.13, "90th_percentile": 129.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 458.41, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 458.41, "10th_percentile": 458.41, "90th_percentile": 458.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 154.96, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 154.96, "10th_percentile": 154.96, "90th_percentile": 154.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 154.96, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 154.96, "10th_percentile": 154.96, "90th_percentile": 154.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 315.8, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 315.8, "10th_percentile": 315.8, "90th_percentile": 315.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 315.8, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 315.8, "10th_percentile": 315.8, "90th_percentile": 315.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 238.89, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.51, "10th_percentile": 5.51, "90th_percentile": 5.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 403.53, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 403.53, "10th_percentile": 403.53, "90th_percentile": 403.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 645.65, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 645.65, "10th_percentile": 645.65, "90th_percentile": 645.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 807.06, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $807.06 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 807.06, "10th_percentile": 807.06, "90th_percentile": 807.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $807.06 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 645.65, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 645.65, "10th_percentile": 645.65, "90th_percentile": 645.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 605.3, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 605.3, "10th_percentile": 605.3, "90th_percentile": 605.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 150.92, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 150.92, "10th_percentile": 150.92, "90th_percentile": 150.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 273.59, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 273.59, "10th_percentile": 273.59, "90th_percentile": 273.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 807.06, "10th_percentile": 807.06, "90th_percentile": 807.06, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 807.06, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 807.06, "10th_percentile": 807.06, "90th_percentile": 807.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 807.06, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 807.06, "10th_percentile": 807.06, "90th_percentile": 807.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "ACCESSORY KT ARTHSCP ANT CRUC LIG ACL DISP", "code_information": [ { "code": "SUP-126551", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 208.46, "maximum": 1302.88, "setting": "outpatient", "gross_charge": 1302.88, "discounted_cash": 912.02, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 280.12, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 373.87, "10th_percentile": 373.87, "90th_percentile": 373.87, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 665.77, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 252.68, "10th_percentile": 252.68, "90th_percentile": 252.68, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 208.46, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 208.46, "10th_percentile": 208.46, "90th_percentile": 208.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 208.46, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 208.46, "10th_percentile": 208.46, "90th_percentile": 208.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 208.46, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 208.46, "10th_percentile": 208.46, "90th_percentile": 208.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 740.04, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 740.04, "10th_percentile": 740.04, "90th_percentile": 740.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 740.04, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 740.04, "10th_percentile": 740.04, "90th_percentile": 740.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 250.15, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 250.15, "10th_percentile": 250.15, "90th_percentile": 250.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 250.15, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 250.15, "10th_percentile": 250.15, "90th_percentile": 250.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 509.82, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 509.82, "10th_percentile": 509.82, "90th_percentile": 509.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 509.82, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 509.82, "10th_percentile": 509.82, "90th_percentile": 509.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 385.65, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.51, "10th_percentile": 5.51, "90th_percentile": 5.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 781.73, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 781.73, "10th_percentile": 781.73, "90th_percentile": 781.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 651.44, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 651.44, "10th_percentile": 651.44, "90th_percentile": 651.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1042.3, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1042.3, "10th_percentile": 1042.3, "90th_percentile": 1042.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1302.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,302.88 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1302.88, "10th_percentile": 1302.88, "90th_percentile": 1302.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,302.88 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1042.3, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1042.3, "10th_percentile": 1042.3, "90th_percentile": 1042.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1107.45, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1107.45, "10th_percentile": 1107.45, "90th_percentile": 1107.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 977.16, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 977.16, "10th_percentile": 977.16, "90th_percentile": 977.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 651.44, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 651.44, "10th_percentile": 651.44, "90th_percentile": 651.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 836.84, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 836.84, "10th_percentile": 836.84, "90th_percentile": 836.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1302.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1302.88, "10th_percentile": 1302.88, "90th_percentile": 1302.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 912.02, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 912.02, "10th_percentile": 912.02, "90th_percentile": 912.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 243.64, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 243.64, "10th_percentile": 243.64, "90th_percentile": 243.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 590.2, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 590.2, "10th_percentile": 590.2, "90th_percentile": 590.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 441.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 441.68, "10th_percentile": 441.68, "90th_percentile": 441.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 977.16, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 977.16, "10th_percentile": 977.16, "90th_percentile": 977.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1302.88, "10th_percentile": 1302.88, "90th_percentile": 1302.88, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1302.88, "10th_percentile": 1302.88, "90th_percentile": 1302.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1302.88, "10th_percentile": 1302.88, "90th_percentile": 1302.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1302.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1302.88, "10th_percentile": 1302.88, "90th_percentile": 1302.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1302.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1302.88, "10th_percentile": 1302.88, "90th_percentile": 1302.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1302.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1302.88, "10th_percentile": 1302.88, "90th_percentile": 1302.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1302.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1302.88, "10th_percentile": 1302.88, "90th_percentile": 1302.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1302.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1302.88, "10th_percentile": 1302.88, "90th_percentile": 1302.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1302.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1302.88, "10th_percentile": 1302.88, "90th_percentile": 1302.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1302.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1302.88, "10th_percentile": 1302.88, "90th_percentile": 1302.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1302.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1302.88, "10th_percentile": 1302.88, "90th_percentile": 1302.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "ACETAZOLAMIDE 125 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-112", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "70756-0720-11", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1.7, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1.7, "10th_percentile": 1.7, "90th_percentile": 1.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1.2, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1.2, "10th_percentile": 1.2, "90th_percentile": 1.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1.28, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1.28, "10th_percentile": 1.28, "90th_percentile": 1.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1.4, "10th_percentile": 1.4, "90th_percentile": 1.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 0.91, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.91, "10th_percentile": 0.91, "90th_percentile": 0.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1.02, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.02, "10th_percentile": 1.02, "90th_percentile": 1.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.89, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.89, "10th_percentile": 0.89, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.89, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.89, "10th_percentile": 0.89, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.43, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.37, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.37, "10th_percentile": 0.37, "90th_percentile": 0.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.68, "10th_percentile": 0.68, "90th_percentile": 0.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.28, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.28, "10th_percentile": 0.28, "90th_percentile": 0.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.29, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.29, "10th_percentile": 0.29, "90th_percentile": 0.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.34, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.34, "10th_percentile": 0.34, "90th_percentile": 0.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.59, "10th_percentile": 0.59, "90th_percentile": 0.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "ACETYLCYSTEINE 200 MG/ML (20 %) IV SOLN", "drug_information": { "unit": 3.0, "type": "ML" }, "code_information": [ { "code": "RX-97031", "type": "CDM" }, { "code": "J0132", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "70594-0111-02", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.74, "maximum": 12.75, "setting": "outpatient", "gross_charge": 12.75, "discounted_cash": 8.92, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12.75, "10th_percentile": 12.75, "90th_percentile": 12.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12.75, "10th_percentile": 12.75, "90th_percentile": 12.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12.75, "10th_percentile": 12.75, "90th_percentile": 12.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12.75, "10th_percentile": 12.75, "90th_percentile": 12.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12.75, "10th_percentile": 12.75, "90th_percentile": 12.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12.75, "10th_percentile": 12.75, "90th_percentile": 12.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12.75, "10th_percentile": 12.75, "90th_percentile": 12.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12.75, "10th_percentile": 12.75, "90th_percentile": 12.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 12.75, "10th_percentile": 12.75, "90th_percentile": 12.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 12.75, "10th_percentile": 12.75, "90th_percentile": 12.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 12.75, "10th_percentile": 12.75, "90th_percentile": 12.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 4.99, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.99, "10th_percentile": 4.99, "90th_percentile": 4.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 4.99, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.99, "10th_percentile": 4.99, "90th_percentile": 4.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 12.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $12.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 12.75, "10th_percentile": 12.75, "90th_percentile": 12.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $12.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 10.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.2, "10th_percentile": 10.2, "90th_percentile": 10.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 2.74, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 2.74, "10th_percentile": 2.74, "90th_percentile": 2.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 4.32, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 4.32, "10th_percentile": 4.32, "90th_percentile": 4.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 6.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.38, "10th_percentile": 6.38, "90th_percentile": 6.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 10.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 10.2, "10th_percentile": 10.2, "90th_percentile": 10.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 7.65, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 7.65, "10th_percentile": 7.65, "90th_percentile": 7.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 9.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 9.56, "10th_percentile": 9.56, "90th_percentile": 9.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 12.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 12.75, "10th_percentile": 12.75, "90th_percentile": 12.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 10.84, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 10.84, "10th_percentile": 10.84, "90th_percentile": 10.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 8.93, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 8.93, "10th_percentile": 8.93, "90th_percentile": 8.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 6.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 6.38, "10th_percentile": 6.38, "90th_percentile": 6.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 9.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 9.56, "10th_percentile": 9.56, "90th_percentile": 9.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" } ] } ] }, { "description": "ACUTE MAJOR EYE INFECTIONS WITH CC/MCC", "code_information": [ { "code": "121", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 8277.85, "maximum": 16943.46, "setting": "inpatient", "gross_charge": 22637.5, "discounted_cash": 15846.25, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_dollar": 8277.85, "standard_charge_algorithm": "Re-evaluated: HLB.838025932; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.16, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Transfer payment: $4,287.18; Additional payment reduction: $42.87; Total: $4,244.31", "median_amount": 8700.91, "10th_percentile": 8700.91, "90th_percentile": 8700.91, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.838025932; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.16, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Transfer payment: $4,287.18; Additional payment reduction: $42.87; Total: $4,244.31" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_dollar": 8277.85, "standard_charge_algorithm": "Re-evaluated: HLB.838025932; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.16, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Transfer payment: $4,287.18; Additional payment reduction: $42.87; Total: $4,244.31", "median_amount": 8700.91, "10th_percentile": 8700.91, "90th_percentile": 8700.91, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.838025932; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.16, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Transfer payment: $4,287.18; Additional payment reduction: $42.87; Total: $4,244.31" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Re-evaluated: HLB.838025932; Using historical claim(s); Scope: All Financial Classes; Cases: 1; INPATIENT; 80% Billed", "median_amount": 18113.6, "10th_percentile": 18113.6, "90th_percentile": 18113.6, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Re-evaluated: HLB.838025932; Using historical claim(s); Scope: All Financial Classes; Cases: 1; Inpatient; 80% Billed", "median_amount": 18113.6, "10th_percentile": 18113.6, "90th_percentile": 18113.6, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 30.4, "standard_charge_algorithm": "Re-evaluated: HLB.838025932; Using historical claim(s); Scope: All Financial Classes; Cases: 1; IP Services. ADP RATE (for patient estimates only); 30.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6883.17, "10th_percentile": 6883.17, "90th_percentile": 6883.17, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_percentage": 21.5, "standard_charge_algorithm": "Additional drugs, labs, radiology services, and other services can be included in reimbursement.", "median_amount": 4868.05, "10th_percentile": 4868.05, "90th_percentile": 4868.05, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_percentage": 34.2, "standard_charge_algorithm": "Re-evaluated: HLB.838025932; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All Inpatient Services; 34.2% Billed", "median_amount": 7743.56, "10th_percentile": 7743.56, "90th_percentile": 7743.56, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Re-evaluated: HLB.838025932; Using historical claim(s); Scope: All Financial Classes; Cases: 1; Inpatient Services; 50% Billed", "median_amount": 11321.0, "10th_percentile": 11321.0, "90th_percentile": 11321.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, and other services can be included in reimbursement.", "median_amount": 11321.01, "10th_percentile": 11321.01, "90th_percentile": 11321.01, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Re-evaluated: HLB.838025932; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; 75% Billed", "median_amount": 16981.5, "10th_percentile": 16981.5, "90th_percentile": 16981.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.838025932; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services - OON; 100% Billed", "median_amount": 22642.0, "10th_percentile": 22642.0, "90th_percentile": 22642.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.838025932; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; 100% Billed", "median_amount": 22642.0, "10th_percentile": 22642.0, "90th_percentile": 22642.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.838025932; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; 100% Billed", "median_amount": 22642.0, "10th_percentile": 22642.0, "90th_percentile": 22642.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.838025932; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; 100% Billed", "median_amount": 22642.0, "10th_percentile": 22642.0, "90th_percentile": 22642.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.838025932; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; 100% Billed", "median_amount": 22642.0, "10th_percentile": 22642.0, "90th_percentile": 22642.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.838025932; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; 100% Billed", "median_amount": 22642.0, "10th_percentile": 22642.0, "90th_percentile": 22642.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.838025932; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; 100% Billed", "median_amount": 22642.0, "10th_percentile": 22642.0, "90th_percentile": 22642.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.838025932; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; 100% Billed", "median_amount": 22642.0, "10th_percentile": 22642.0, "90th_percentile": 22642.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.838025932; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; 100% Billed", "median_amount": 22642.0, "10th_percentile": 22642.0, "90th_percentile": 22642.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 16943.46, "standard_charge_algorithm": "Re-evaluated: HLB.838025932; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1633, Rate: 14,565.00, and; Pricing Extension - NM HB XR PRC - PH BCBS PPO STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16943.46, "10th_percentile": 16943.46, "90th_percentile": 16943.46, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 11966.87, "standard_charge_algorithm": "Re-evaluated: HLB.838025932; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1633, Rate: 10,287.00, and; Pricing Extension - NM HB XR PRC - PH BCBS HMO STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11966.87, "10th_percentile": 11966.87, "90th_percentile": 11966.87, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 16943.46, "standard_charge_algorithm": "Re-evaluated: HLB.838025932; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1633, Rate: 14,565.00, and; Pricing Extension - NM HB XR PRC - PH BCBS PPO STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16943.46, "10th_percentile": 16943.46, "90th_percentile": 16943.46, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 9312.22, "standard_charge_algorithm": "Re-evaluated: HLB.838025932; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1633, Rate: 8,005.00, and; Pricing Extension - NM HB XR PRC - PH BCBS CHOICE SELECT STOP LOSS & LESSOR OF *; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9312.22, "10th_percentile": 9312.22, "90th_percentile": 9312.22, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 10522.05, "standard_charge_algorithm": "Re-evaluated: HLB.838025932; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1633, Rate: 9,045.00, and; Pricing Extension - NM HB XR PRC - PH BCBS CHOICE STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10522.05, "10th_percentile": 10522.05, "90th_percentile": 10522.05, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 9963.66, "standard_charge_algorithm": "Re-evaluated: HLB.838025932; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1633, Rate: 8,565.00, and; Pricing Extension - NM HB XR PRC - PH BCBS CHOICE PREF STOP LOSS & LESSOR OF 9.*; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9963.66, "10th_percentile": 9963.66, "90th_percentile": 9963.66, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 11966.87, "standard_charge_algorithm": "Re-evaluated: HLB.838025932; Using historical claim(s); Scope: All Financial Classes; Cases: 1; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1633, Rate: 10,287.00, and; Pricing Extension - NM HB XR PRC - PH BCBS HMO STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11966.87, "10th_percentile": 11966.87, "90th_percentile": 11966.87, "count": "1 through 10", "methodology": "case rate" } ] } ] }, { "description": "ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC", "code_information": [ { "code": "283", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 6110.78, "maximum": 28850.35, "setting": "inpatient", "gross_charge": 51436.31, "discounted_cash": 36005.42, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_dollar": 14095.04, "standard_charge_algorithm": "Re-evaluated: HLB.817769469; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.98, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $14,965.06; Additional payment reduction: $149.65; Total: $14,815.41", "median_amount": 14815.41, "10th_percentile": 14815.41, "90th_percentile": 14815.41, "count": "11", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.817769469; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.98, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $14,965.06; Additional payment reduction: $149.65; Total: $14,815.41" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_dollar": 14095.04, "standard_charge_algorithm": "Re-evaluated: HLB.817769469; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.98, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $14,965.06; Additional payment reduction: $149.65; Total: $14,815.41", "median_amount": 14815.41, "10th_percentile": 14815.41, "90th_percentile": 14815.41, "count": "11", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.817769469; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.98, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $14,965.06; Additional payment reduction: $149.65; Total: $14,815.41" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.817769469; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; 100% Billed", "median_amount": 51270.07, "10th_percentile": 51270.07, "90th_percentile": 51270.07, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.817769469; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; 100% Billed", "median_amount": 51270.07, "10th_percentile": 51270.07, "90th_percentile": 51270.07, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.817769469; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; 100% Billed", "median_amount": 51270.07, "10th_percentile": 51270.07, "90th_percentile": 51270.07, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.817769469; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; 100% Billed", "median_amount": 51270.07, "10th_percentile": 51270.07, "90th_percentile": 51270.07, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.817769469; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; 100% Billed", "median_amount": 51270.07, "10th_percentile": 51270.07, "90th_percentile": 51270.07, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.817769469; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; 100% Billed", "median_amount": 51270.07, "10th_percentile": 51270.07, "90th_percentile": 51270.07, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.817769469; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; 100% Billed", "median_amount": 51270.07, "10th_percentile": 51270.07, "90th_percentile": 51270.07, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.817769469; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; 100% Billed", "median_amount": 51270.07, "10th_percentile": 51270.07, "90th_percentile": 51270.07, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.817769469; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services - OON; 100% Billed", "median_amount": 51270.07, "10th_percentile": 51270.07, "90th_percentile": 51270.07, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Re-evaluated: HLB.817769469; Using historical claim(s); Scope: All Financial Classes; Cases: 11; Inpatient; 80% Billed", "median_amount": 41016.06, "10th_percentile": 41016.06, "90th_percentile": 41016.06, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 30.4, "standard_charge_algorithm": "Re-evaluated: HLB.817769469; Using historical claim(s); Scope: All Financial Classes; Cases: 11; IP Services. ADP RATE (for patient estimates only); 30.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15586.1, "10th_percentile": 15586.1, "90th_percentile": 15586.1, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_percentage": 21.5, "standard_charge_algorithm": "Additional anesthesia services, drugs, imaging services, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 4650.63, "10th_percentile": 4650.63, "90th_percentile": 4650.63, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_percentage": 34.2, "standard_charge_algorithm": "Re-evaluated: HLB.817769469; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All Inpatient Services; 34.2% Billed", "median_amount": 17534.36, "10th_percentile": 17534.36, "90th_percentile": 17534.36, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, imaging services, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 25635.04, "10th_percentile": 25635.04, "90th_percentile": 25635.04, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Re-evaluated: HLB.817769469; Using historical claim(s); Scope: All Financial Classes; Cases: 11; Inpatient Services; 50% Billed", "median_amount": 25635.04, "10th_percentile": 25635.04, "90th_percentile": 25635.04, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, imaging services, labs, radiology services, supplies, and other services can be included in reimbursement.", "median_amount": 38452.55, "10th_percentile": 38452.55, "90th_percentile": 38452.55, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Re-evaluated: HLB.817769469; Using historical claim(s); Scope: All Financial Classes; Cases: 11; STOP LOSS; 75% Billed", "median_amount": 38452.55, "10th_percentile": 38452.55, "90th_percentile": 38452.55, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Re-evaluated: HLB.817769469; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; 75% Billed", "median_amount": 38452.55, "10th_percentile": 38452.55, "90th_percentile": 38452.55, "count": "11", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 20376.49, "standard_charge_algorithm": "Re-evaluated: HLB.817769469; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.9808, Rate: 10,287.00, and; Pricing Extension - NM HB XR PRC - PH BCBS HMO STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20376.49, "10th_percentile": 20376.49, "90th_percentile": 20376.49, "count": "11", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 16965.55, "standard_charge_algorithm": "Re-evaluated: HLB.817769469; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.9808, Rate: 8,565.00, and; Pricing Extension - NM HB XR PRC - PH BCBS CHOICE PREF STOP LOSS & LESSOR OF 9.*; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16965.55, "10th_percentile": 16965.55, "90th_percentile": 16965.55, "count": "11", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 28850.35, "standard_charge_algorithm": "Re-evaluated: HLB.817769469; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.9808, Rate: 14,565.00, and; Pricing Extension - NM HB XR PRC - PH BCBS PPO STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28850.35, "10th_percentile": 28850.35, "90th_percentile": 28850.35, "count": "11", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 15856.3, "standard_charge_algorithm": "Re-evaluated: HLB.817769469; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.9808, Rate: 8,005.00, and; Pricing Extension - NM HB XR PRC - PH BCBS CHOICE SELECT STOP LOSS & LESSOR OF *; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15856.3, "10th_percentile": 15856.3, "90th_percentile": 15856.3, "count": "11", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 17916.34, "standard_charge_algorithm": "Re-evaluated: HLB.817769469; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.9808, Rate: 9,045.00, and; Pricing Extension - NM HB XR PRC - PH BCBS CHOICE STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17916.34, "10th_percentile": 17916.34, "90th_percentile": 17916.34, "count": "11", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 20376.49, "standard_charge_algorithm": "Re-evaluated: HLB.817769469; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.9808, Rate: 10,287.00, and; Pricing Extension - NM HB XR PRC - PH BCBS HMO STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20376.49, "10th_percentile": 20376.49, "90th_percentile": 20376.49, "count": "11", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 28850.35, "standard_charge_algorithm": "Re-evaluated: HLB.817769469; Using historical claim(s); Scope: All Financial Classes; Cases: 11; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.9808, Rate: 14,565.00, and; Pricing Extension - NM HB XR PRC - PH BCBS PPO STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28850.35, "10th_percentile": 28850.35, "90th_percentile": 28850.35, "count": "11", "methodology": "case rate" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 6110.78, "standard_charge_algorithm": "Re-evaluated: HLB.817769469; Using historical claim(s); Scope: All Financial Classes; Cases: 11; ICU; Per Diem @ $6,110.78, and; Pricing Extension - HB XR PRC - Lesser of Terms or 75%; Note: Paid at contractual rate, which is the lesser of contractual and 75% of charges. Total pmt for all lines paid so far is less than 75% of claim billed amount.", "median_amount": 11077.09, "10th_percentile": 11077.09, "90th_percentile": 11077.09, "count": "11", "methodology": "per diem" } ] } ] }, { "description": "ACYCLOVIR 800 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-8972", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "50268-0062-15", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.38, "maximum": 2.75, "setting": "outpatient", "gross_charge": 2.75, "discounted_cash": 1.92, "payers_information": [ { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1.77, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1.77, "10th_percentile": 1.77, "90th_percentile": 1.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1.65, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1.65, "10th_percentile": 1.65, "90th_percentile": 1.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1.41, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.41, "10th_percentile": 1.41, "90th_percentile": 1.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 1.25, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.25, "10th_percentile": 1.25, "90th_percentile": 1.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1.93, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1.93, "10th_percentile": 1.93, "90th_percentile": 1.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 2.06, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 2.06, "10th_percentile": 2.06, "90th_percentile": 2.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.59, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.59, "10th_percentile": 0.59, "90th_percentile": 0.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.51, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.51, "10th_percentile": 0.51, "90th_percentile": 0.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 2.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.2, "10th_percentile": 2.2, "90th_percentile": 2.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.38, "10th_percentile": 1.38, "90th_percentile": 1.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.93, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.93, "10th_percentile": 0.93, "90th_percentile": 0.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.38, "10th_percentile": 1.38, "90th_percentile": 1.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1.22, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.22, "10th_percentile": 1.22, "90th_percentile": 1.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 2.06, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 2.06, "10th_percentile": 2.06, "90th_percentile": 2.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 2.34, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 2.34, "10th_percentile": 2.34, "90th_percentile": 2.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 2.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 2.2, "10th_percentile": 2.2, "90th_percentile": 2.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1.08, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.08, "10th_percentile": 1.08, "90th_percentile": 1.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 0.81, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.81, "10th_percentile": 0.81, "90th_percentile": 0.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1.08, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.08, "10th_percentile": 1.08, "90th_percentile": 1.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.47, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.47, "10th_percentile": 0.47, "90th_percentile": 0.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.39, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.39, "10th_percentile": 0.39, "90th_percentile": 0.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.38, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.38, "10th_percentile": 0.38, "90th_percentile": 0.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1.22, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.22, "10th_percentile": 1.22, "90th_percentile": 1.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.56, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.56, "10th_percentile": 1.56, "90th_percentile": 1.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.56, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.56, "10th_percentile": 1.56, "90th_percentile": 1.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "ACYCLOVIR SODIUM 50 MG/ML IV SOLN", "drug_information": { "unit": 10.0, "type": "ML" }, "code_information": [ { "code": "RX-23128", "type": "CDM" }, { "code": "J0133", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "65219-0622-02", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.44, "maximum": 16.0, "setting": "outpatient", "gross_charge": 16.0, "discounted_cash": 11.2, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 16.0, "10th_percentile": 16.0, "90th_percentile": 16.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 16.0, "10th_percentile": 16.0, "90th_percentile": 16.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 16.0, "10th_percentile": 16.0, "90th_percentile": 16.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 5.42, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 5.42, "10th_percentile": 5.42, "90th_percentile": 5.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 3.44, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 3.44, "10th_percentile": 3.44, "90th_percentile": 3.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 12.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 12.8, "10th_percentile": 12.8, "90th_percentile": 12.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 8.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.0, "10th_percentile": 8.0, "90th_percentile": 8.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 12.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.8, "10th_percentile": 12.8, "90th_percentile": 12.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 12.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 12.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 13.6, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 13.6, "10th_percentile": 13.6, "90th_percentile": 13.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 8.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 8.0, "10th_percentile": 8.0, "90th_percentile": 8.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 9.6, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 9.6, "10th_percentile": 9.6, "90th_percentile": 9.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 11.2, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 11.2, "10th_percentile": 11.2, "90th_percentile": 11.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 16.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 16.0, "10th_percentile": 16.0, "90th_percentile": 16.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 16.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $16.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 16.0, "10th_percentile": 16.0, "90th_percentile": 16.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $16.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 6.26, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.26, "10th_percentile": 6.26, "90th_percentile": 6.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 6.26, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.26, "10th_percentile": 6.26, "90th_percentile": 6.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 16.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 16.0, "10th_percentile": 16.0, "90th_percentile": 16.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 16.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 16.0, "10th_percentile": 16.0, "90th_percentile": 16.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 16.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 16.0, "10th_percentile": 16.0, "90th_percentile": 16.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 16.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 16.0, "10th_percentile": 16.0, "90th_percentile": 16.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 16.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 16.0, "10th_percentile": 16.0, "90th_percentile": 16.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 16.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 16.0, "10th_percentile": 16.0, "90th_percentile": 16.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 16.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 16.0, "10th_percentile": 16.0, "90th_percentile": 16.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 16.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 16.0, "10th_percentile": 16.0, "90th_percentile": 16.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "ADAPTER PHOTONGUIDE ILLUMINATED RETRACTOR SYSTEM INVUITY", "code_information": [ { "code": "SUP-416494", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 99.51, "maximum": 711.32, "setting": "outpatient", "gross_charge": 711.32, "discounted_cash": 497.92, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 120.43, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 120.43, "10th_percentile": 120.43, "90th_percentile": 120.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 314.97, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 314.97, "10th_percentile": 314.97, "90th_percentile": 314.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 278.34, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 278.34, "10th_percentile": 278.34, "90th_percentile": 278.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 101.51, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 101.51, "10th_percentile": 101.51, "90th_percentile": 101.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 99.51, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 99.51, "10th_percentile": 99.51, "90th_percentile": 99.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 711.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $711.32 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 711.32, "10th_percentile": 711.32, "90th_percentile": 711.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $711.32 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 604.62, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 604.62, "10th_percentile": 604.62, "90th_percentile": 604.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 456.88, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 456.88, "10th_percentile": 456.88, "90th_percentile": 456.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 355.66, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 355.66, "10th_percentile": 355.66, "90th_percentile": 355.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 241.14, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 241.14, "10th_percentile": 241.14, "90th_percentile": 241.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 497.92, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 497.92, "10th_percentile": 497.92, "90th_percentile": 497.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 533.49, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 533.49, "10th_percentile": 533.49, "90th_percentile": 533.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 314.97, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 314.97, "10th_percentile": 314.97, "90th_percentile": 314.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 355.66, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 355.66, "10th_percentile": 355.66, "90th_percentile": 355.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 569.06, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 569.06, "10th_percentile": 569.06, "90th_percentile": 569.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 426.79, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 426.79, "10th_percentile": 426.79, "90th_percentile": 426.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 152.93, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 152.93, "10th_percentile": 152.93, "90th_percentile": 152.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 278.34, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 278.34, "10th_percentile": 278.34, "90th_percentile": 278.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 533.49, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 533.49, "10th_percentile": 533.49, "90th_percentile": 533.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 210.55, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 210.55, "10th_percentile": 210.55, "90th_percentile": 210.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 133.02, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 133.02, "10th_percentile": 133.02, "90th_percentile": 133.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 569.06, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 569.06, "10th_percentile": 569.06, "90th_percentile": 569.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 711.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 711.32, "10th_percentile": 711.32, "90th_percentile": 711.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 322.23, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 322.23, "10th_percentile": 322.23, "90th_percentile": 322.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 363.48, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 363.48, "10th_percentile": 363.48, "90th_percentile": 363.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 404.03, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 404.03, "10th_percentile": 404.03, "90th_percentile": 404.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 404.03, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 404.03, "10th_percentile": 404.03, "90th_percentile": 404.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 711.32, "10th_percentile": 711.32, "90th_percentile": 711.32, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 711.32, "10th_percentile": 711.32, "90th_percentile": 711.32, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 711.32, "10th_percentile": 711.32, "90th_percentile": 711.32, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 711.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 711.32, "10th_percentile": 711.32, "90th_percentile": 711.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 711.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 711.32, "10th_percentile": 711.32, "90th_percentile": 711.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 711.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 711.32, "10th_percentile": 711.32, "90th_percentile": 711.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 711.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 711.32, "10th_percentile": 711.32, "90th_percentile": 711.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 711.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 711.32, "10th_percentile": 711.32, "90th_percentile": 711.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 711.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 711.32, "10th_percentile": 711.32, "90th_percentile": 711.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 711.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 711.32, "10th_percentile": 711.32, "90th_percentile": 711.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 711.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 711.32, "10th_percentile": 711.32, "90th_percentile": 711.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "ADPT HUM HD 7DIAX170LG RVRS FX HMROPRSTHS AEQ", "code_information": [ { "code": "SUP-314004", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 1147.82, "maximum": 7173.88, "setting": "outpatient", "gross_charge": 7173.88, "discounted_cash": 5021.72, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 3665.85, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2248.51, "10th_percentile": 2248.51, "90th_percentile": 2248.51, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1147.82, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1147.82, "10th_percentile": 1147.82, "90th_percentile": 1147.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 1147.82, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1147.82, "10th_percentile": 1147.82, "90th_percentile": 1147.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1147.82, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1147.82, "10th_percentile": 1147.82, "90th_percentile": 1147.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 7173.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $7,173.88 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 7173.88, "10th_percentile": 7173.88, "90th_percentile": 7173.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $7,173.88 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 3249.77, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3249.77, "10th_percentile": 3249.77, "90th_percentile": 3249.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 3586.94, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 3586.94, "10th_percentile": 3586.94, "90th_percentile": 3586.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 4304.33, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 4304.33, "10th_percentile": 4304.33, "90th_percentile": 4304.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 4607.78, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 4607.78, "10th_percentile": 4607.78, "90th_percentile": 4607.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 5380.41, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 5380.41, "10th_percentile": 5380.41, "90th_percentile": 5380.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 2431.95, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 2431.95, "10th_percentile": 2431.95, "90th_percentile": 2431.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 5021.72, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 5021.72, "10th_percentile": 5021.72, "90th_percentile": 5021.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 5380.41, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 5380.41, "10th_percentile": 5380.41, "90th_percentile": 5380.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 5739.1, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 5739.1, "10th_percentile": 5739.1, "90th_percentile": 5739.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 7173.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 7173.88, "10th_percentile": 7173.88, "90th_percentile": 7173.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 1341.52, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1341.52, "10th_percentile": 1341.52, "90th_percentile": 1341.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 2123.47, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2123.47, "10th_percentile": 2123.47, "90th_percentile": 2123.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 5739.1, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5739.1, "10th_percentile": 5739.1, "90th_percentile": 5739.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 1542.38, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 1542.38, "10th_percentile": 1542.38, "90th_percentile": 1542.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 3586.94, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3586.94, "10th_percentile": 3586.94, "90th_percentile": 3586.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 6097.8, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 6097.8, "10th_percentile": 6097.8, "90th_percentile": 6097.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1377.38, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1377.38, "10th_percentile": 1377.38, "90th_percentile": 1377.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1377.38, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1377.38, "10th_percentile": 1377.38, "90th_percentile": 1377.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 4074.76, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4074.76, "10th_percentile": 4074.76, "90th_percentile": 4074.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 4074.76, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4074.76, "10th_percentile": 4074.76, "90th_percentile": 4074.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2807.14, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2807.14, "10th_percentile": 2807.14, "90th_percentile": 2807.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2807.14, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2807.14, "10th_percentile": 2807.14, "90th_percentile": 2807.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 7173.88, "10th_percentile": 7173.88, "90th_percentile": 7173.88, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7173.88, "10th_percentile": 7173.88, "90th_percentile": 7173.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7173.88, "10th_percentile": 7173.88, "90th_percentile": 7173.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7173.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7173.88, "10th_percentile": 7173.88, "90th_percentile": 7173.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7173.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7173.88, "10th_percentile": 7173.88, "90th_percentile": 7173.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7173.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7173.88, "10th_percentile": 7173.88, "90th_percentile": 7173.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7173.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7173.88, "10th_percentile": 7173.88, "90th_percentile": 7173.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7173.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7173.88, "10th_percentile": 7173.88, "90th_percentile": 7173.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7173.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7173.88, "10th_percentile": 7173.88, "90th_percentile": 7173.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7173.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7173.88, "10th_percentile": 7173.88, "90th_percentile": 7173.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7173.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7173.88, "10th_percentile": 7173.88, "90th_percentile": 7173.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "ADPT OFST DURAC STD 4MM COCR", "code_information": [ { "code": "SUP-1649", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 356.4, "maximum": 2227.49, "setting": "outpatient", "gross_charge": 2227.49, "discounted_cash": 1559.24, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 356.4, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 356.4, "10th_percentile": 356.4, "90th_percentile": 356.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 356.4, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 356.4, "10th_percentile": 356.4, "90th_percentile": 356.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 755.12, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 755.12, "10th_percentile": 755.12, "90th_percentile": 755.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1781.99, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1781.99, "10th_percentile": 1781.99, "90th_percentile": 1781.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 478.91, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 478.91, "10th_percentile": 478.91, "90th_percentile": 478.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 427.68, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 427.68, "10th_percentile": 427.68, "90th_percentile": 427.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1265.21, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1265.21, "10th_percentile": 1265.21, "90th_percentile": 1265.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 871.62, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 871.62, "10th_percentile": 871.62, "90th_percentile": 871.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2227.49, "10th_percentile": 2227.49, "90th_percentile": 2227.49, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2227.49, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2227.49, "10th_percentile": 2227.49, "90th_percentile": 2227.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1138.25, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2248.51, "10th_percentile": 2248.51, "90th_percentile": 2248.51, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 356.4, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 356.4, "10th_percentile": 356.4, "90th_percentile": 356.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2227.49, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,227.49 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2227.49, "10th_percentile": 2227.49, "90th_percentile": 2227.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,227.49 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1113.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1113.75, "10th_percentile": 1113.75, "90th_percentile": 1113.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1670.62, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1670.62, "10th_percentile": 1670.62, "90th_percentile": 1670.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1430.72, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1430.72, "10th_percentile": 1430.72, "90th_percentile": 1430.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1670.62, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1670.62, "10th_percentile": 1670.62, "90th_percentile": 1670.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 1009.05, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1009.05, "10th_percentile": 1009.05, "90th_percentile": 1009.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1336.49, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1336.49, "10th_percentile": 1336.49, "90th_percentile": 1336.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1559.24, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1559.24, "10th_percentile": 1559.24, "90th_percentile": 1559.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 659.34, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 659.34, "10th_percentile": 659.34, "90th_percentile": 659.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 416.54, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 416.54, "10th_percentile": 416.54, "90th_percentile": 416.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1893.37, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1893.37, "10th_percentile": 1893.37, "90th_percentile": 1893.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2227.49, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2227.49, "10th_percentile": 2227.49, "90th_percentile": 2227.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1781.99, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1781.99, "10th_percentile": 1781.99, "90th_percentile": 1781.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1113.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1113.75, "10th_percentile": 1113.75, "90th_percentile": 1113.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 427.68, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 427.68, "10th_percentile": 427.68, "90th_percentile": 427.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 871.62, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 871.62, "10th_percentile": 871.62, "90th_percentile": 871.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1265.21, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1265.21, "10th_percentile": 1265.21, "90th_percentile": 1265.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2227.49, "10th_percentile": 2227.49, "90th_percentile": 2227.49, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2227.49, "10th_percentile": 2227.49, "90th_percentile": 2227.49, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2227.49, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2227.49, "10th_percentile": 2227.49, "90th_percentile": 2227.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2227.49, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2227.49, "10th_percentile": 2227.49, "90th_percentile": 2227.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2227.49, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2227.49, "10th_percentile": 2227.49, "90th_percentile": 2227.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2227.49, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2227.49, "10th_percentile": 2227.49, "90th_percentile": 2227.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2227.49, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2227.49, "10th_percentile": 2227.49, "90th_percentile": 2227.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2227.49, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2227.49, "10th_percentile": 2227.49, "90th_percentile": 2227.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2227.49, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2227.49, "10th_percentile": 2227.49, "90th_percentile": 2227.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "ADPT SLV FEM C TAPR UNIV +5MM TI", "code_information": [ { "code": "SUP-123261", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 20.5, "maximum": 128.11, "setting": "outpatient", "gross_charge": 128.11, "discounted_cash": 89.68, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 65.46, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2248.51, "10th_percentile": 2248.51, "90th_percentile": 2248.51, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 20.5, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.5, "10th_percentile": 20.5, "90th_percentile": 20.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 20.5, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.5, "10th_percentile": 20.5, "90th_percentile": 20.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 20.5, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.5, "10th_percentile": 20.5, "90th_percentile": 20.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 128.11, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $128.11 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 128.11, "10th_percentile": 128.11, "90th_percentile": 128.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $128.11 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 27.54, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 27.54, "10th_percentile": 27.54, "90th_percentile": 27.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 64.06, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 64.06, "10th_percentile": 64.06, "90th_percentile": 64.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 96.08, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 96.08, "10th_percentile": 96.08, "90th_percentile": 96.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 82.29, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 82.29, "10th_percentile": 82.29, "90th_percentile": 82.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 102.49, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 102.49, "10th_percentile": 102.49, "90th_percentile": 102.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 96.08, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 96.08, "10th_percentile": 96.08, "90th_percentile": 96.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 43.43, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 43.43, "10th_percentile": 43.43, "90th_percentile": 43.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 58.03, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 58.03, "10th_percentile": 58.03, "90th_percentile": 58.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 76.87, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 76.87, "10th_percentile": 76.87, "90th_percentile": 76.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 89.68, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 89.68, "10th_percentile": 89.68, "90th_percentile": 89.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 37.92, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 37.92, "10th_percentile": 37.92, "90th_percentile": 37.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 23.96, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 23.96, "10th_percentile": 23.96, "90th_percentile": 23.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 108.89, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 108.89, "10th_percentile": 108.89, "90th_percentile": 108.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 128.11, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 128.11, "10th_percentile": 128.11, "90th_percentile": 128.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 102.49, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 102.49, "10th_percentile": 102.49, "90th_percentile": 102.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 64.06, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 64.06, "10th_percentile": 64.06, "90th_percentile": 64.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 24.6, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.6, "10th_percentile": 24.6, "90th_percentile": 24.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 24.6, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.6, "10th_percentile": 24.6, "90th_percentile": 24.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 50.13, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 50.13, "10th_percentile": 50.13, "90th_percentile": 50.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 50.13, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 50.13, "10th_percentile": 50.13, "90th_percentile": 50.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 72.77, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 72.77, "10th_percentile": 72.77, "90th_percentile": 72.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 72.77, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 72.77, "10th_percentile": 72.77, "90th_percentile": 72.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 128.11, "10th_percentile": 128.11, "90th_percentile": 128.11, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 128.11, "10th_percentile": 128.11, "90th_percentile": 128.11, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 128.11, "10th_percentile": 128.11, "90th_percentile": 128.11, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 128.11, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 128.11, "10th_percentile": 128.11, "90th_percentile": 128.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 128.11, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 128.11, "10th_percentile": 128.11, "90th_percentile": 128.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 128.11, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 128.11, "10th_percentile": 128.11, "90th_percentile": 128.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 128.11, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 128.11, "10th_percentile": 128.11, "90th_percentile": 128.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 128.11, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 128.11, "10th_percentile": 128.11, "90th_percentile": 128.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 128.11, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 128.11, "10th_percentile": 128.11, "90th_percentile": 128.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 128.11, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 128.11, "10th_percentile": 128.11, "90th_percentile": 128.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 128.11, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 128.11, "10th_percentile": 128.11, "90th_percentile": 128.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "ADPT SLV FEM MRSE C TAPR", "code_information": [ { "code": "SUP-144617", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 47.78, "maximum": 298.61, "setting": "outpatient", "gross_charge": 298.61, "discounted_cash": 209.03, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 47.78, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 47.78, "10th_percentile": 47.78, "90th_percentile": 47.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 47.78, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 47.78, "10th_percentile": 47.78, "90th_percentile": 47.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 47.78, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 47.78, "10th_percentile": 47.78, "90th_percentile": 47.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 298.61, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $298.61 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 298.61, "10th_percentile": 298.61, "90th_percentile": 298.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $298.61 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 64.2, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 64.2, "10th_percentile": 64.2, "90th_percentile": 64.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 238.89, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 238.89, "10th_percentile": 238.89, "90th_percentile": 238.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 101.23, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 101.23, "10th_percentile": 101.23, "90th_percentile": 101.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 57.33, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 57.33, "10th_percentile": 57.33, "90th_percentile": 57.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 57.33, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 57.33, "10th_percentile": 57.33, "90th_percentile": 57.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 116.85, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 116.85, "10th_percentile": 116.85, "90th_percentile": 116.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 116.85, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 116.85, "10th_percentile": 116.85, "90th_percentile": 116.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 169.61, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 169.61, "10th_percentile": 169.61, "90th_percentile": 169.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 298.61, "10th_percentile": 298.61, "90th_percentile": 298.61, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 298.61, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 298.61, "10th_percentile": 298.61, "90th_percentile": 298.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 152.59, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2248.51, "10th_percentile": 2248.51, "90th_percentile": 2248.51, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 169.61, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 169.61, "10th_percentile": 169.61, "90th_percentile": 169.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 88.39, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 88.39, "10th_percentile": 88.39, "90th_percentile": 88.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 298.61, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 298.61, "10th_percentile": 298.61, "90th_percentile": 298.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 223.96, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 223.96, "10th_percentile": 223.96, "90th_percentile": 223.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 238.89, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 238.89, "10th_percentile": 238.89, "90th_percentile": 238.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 223.96, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 223.96, "10th_percentile": 223.96, "90th_percentile": 223.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 191.8, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 191.8, "10th_percentile": 191.8, "90th_percentile": 191.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 149.31, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 149.31, "10th_percentile": 149.31, "90th_percentile": 149.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 135.27, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 135.27, "10th_percentile": 135.27, "90th_percentile": 135.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 209.03, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 209.03, "10th_percentile": 209.03, "90th_percentile": 209.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 179.17, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 179.17, "10th_percentile": 179.17, "90th_percentile": 179.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 253.82, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 253.82, "10th_percentile": 253.82, "90th_percentile": 253.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 149.31, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 149.31, "10th_percentile": 149.31, "90th_percentile": 149.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 55.84, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 55.84, "10th_percentile": 55.84, "90th_percentile": 55.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 298.61, "10th_percentile": 298.61, "90th_percentile": 298.61, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 298.61, "10th_percentile": 298.61, "90th_percentile": 298.61, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 298.61, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 298.61, "10th_percentile": 298.61, "90th_percentile": 298.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 298.61, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 298.61, "10th_percentile": 298.61, "90th_percentile": 298.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 298.61, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 298.61, "10th_percentile": 298.61, "90th_percentile": 298.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 298.61, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 298.61, "10th_percentile": 298.61, "90th_percentile": 298.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 298.61, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 298.61, "10th_percentile": 298.61, "90th_percentile": 298.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 298.61, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 298.61, "10th_percentile": 298.61, "90th_percentile": 298.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 298.61, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 298.61, "10th_percentile": 298.61, "90th_percentile": 298.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC", "code_information": [ { "code": "560", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 8013.14, "maximum": 16401.65, "setting": "inpatient", "gross_charge": 25701.24, "discounted_cash": 17990.87, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_dollar": 8013.14, "standard_charge_algorithm": "Re-evaluated: HLB.752841182; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.13, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Transfer payment: $8,507.76; Additional payment reduction: $85.08; Total: $8,422.68", "median_amount": 8422.68, "10th_percentile": 8422.68, "90th_percentile": 8422.68, "count": "13", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.752841182; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.13, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Transfer payment: $8,507.76; Additional payment reduction: $85.08; Total: $8,422.68" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_dollar": 8013.14, "standard_charge_algorithm": "Re-evaluated: HLB.752841182; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.13, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Transfer payment: $8,507.76; Additional payment reduction: $85.08; Total: $8,422.68", "median_amount": 8422.68, "10th_percentile": 8422.68, "90th_percentile": 8422.68, "count": "13", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.752841182; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.13, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Transfer payment: $8,507.76; Additional payment reduction: $85.08; Total: $8,422.68" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.752841182; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services - OON; 100% Billed", "median_amount": 25667.5, "10th_percentile": 25667.5, "90th_percentile": 25667.5, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.752841182; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services; 100% Billed", "median_amount": 25667.5, "10th_percentile": 25667.5, "90th_percentile": 25667.5, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.752841182; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services; 100% Billed", "median_amount": 25667.5, "10th_percentile": 25667.5, "90th_percentile": 25667.5, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.752841182; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services; 100% Billed", "median_amount": 25667.5, "10th_percentile": 25667.5, "90th_percentile": 25667.5, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.752841182; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services; 100% Billed", "median_amount": 25667.5, "10th_percentile": 25667.5, "90th_percentile": 25667.5, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.752841182; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services; 100% Billed", "median_amount": 25667.5, "10th_percentile": 25667.5, "90th_percentile": 25667.5, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.752841182; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services; 100% Billed", "median_amount": 25667.5, "10th_percentile": 25667.5, "90th_percentile": 25667.5, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.752841182; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services; 100% Billed", "median_amount": 25667.5, "10th_percentile": 25667.5, "90th_percentile": 25667.5, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.752841182; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services; 100% Billed", "median_amount": 25667.5, "10th_percentile": 25667.5, "90th_percentile": 25667.5, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_percentage": 34.2, "standard_charge_algorithm": "Re-evaluated: HLB.752841182; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All Inpatient Services; 34.2% Billed", "median_amount": 8778.29, "10th_percentile": 8778.29, "90th_percentile": 8778.29, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_percentage": 21.5, "standard_charge_algorithm": "Additional drugs, labs, radiology services, therapy services, and other services can be included in reimbursement.", "median_amount": 5518.56, "10th_percentile": 5518.56, "90th_percentile": 5518.56, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Additional drugs, labs, therapy services, and other services can be included in reimbursement.", "median_amount": 17444.35, "10th_percentile": 17444.35, "90th_percentile": 17444.35, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 30.4, "standard_charge_algorithm": "Re-evaluated: HLB.752841182; Using historical claim(s); Scope: All Financial Classes; Cases: 13; IP Services. ADP RATE (for patient estimates only); 30.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7802.92, "10th_percentile": 7802.92, "90th_percentile": 7802.92, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Re-evaluated: HLB.752841182; Using historical claim(s); Scope: All Financial Classes; Cases: 13; Inpatient; 80% Billed", "median_amount": 20534.0, "10th_percentile": 20534.0, "90th_percentile": 20534.0, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Re-evaluated: HLB.752841182; Using historical claim(s); Scope: All Financial Classes; Cases: 13; INPATIENT; 80% Billed", "median_amount": 20534.0, "10th_percentile": 20534.0, "90th_percentile": 20534.0, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, therapy services, and other services can be included in reimbursement.", "median_amount": 19250.63, "10th_percentile": 19250.63, "90th_percentile": 19250.63, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Re-evaluated: HLB.752841182; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services; 75% Billed", "median_amount": 19250.63, "10th_percentile": 19250.63, "90th_percentile": 19250.63, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, therapy services, and other services can be included in reimbursement.", "median_amount": 12833.75, "10th_percentile": 12833.75, "90th_percentile": 12833.75, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Re-evaluated: HLB.752841182; Using historical claim(s); Scope: All Financial Classes; Cases: 13; Inpatient Services; 50% Billed", "median_amount": 12833.75, "10th_percentile": 12833.75, "90th_percentile": 12833.75, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 16401.65, "standard_charge_algorithm": "Re-evaluated: HLB.752841182; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 14,565.00, and; Pricing Extension - NM HB XR PRC - PH BCBS PPO STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16401.65, "10th_percentile": 16401.65, "90th_percentile": 16401.65, "count": "13", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 9014.43, "standard_charge_algorithm": "Re-evaluated: HLB.752841182; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 8,005.00, and; Pricing Extension - NM HB XR PRC - PH BCBS CHOICE SELECT STOP LOSS & LESSOR OF *; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9014.43, "10th_percentile": 9014.43, "90th_percentile": 9014.43, "count": "13", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 10185.57, "standard_charge_algorithm": "Re-evaluated: HLB.752841182; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 9,045.00, and; Pricing Extension - NM HB XR PRC - PH BCBS CHOICE STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10185.57, "10th_percentile": 10185.57, "90th_percentile": 10185.57, "count": "13", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 9645.05, "standard_charge_algorithm": "Re-evaluated: HLB.752841182; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 8,565.00, and; Pricing Extension - NM HB XR PRC - PH BCBS CHOICE PREF STOP LOSS & LESSOR OF 9.*; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9645.05, "10th_percentile": 9645.05, "90th_percentile": 9645.05, "count": "13", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 11584.19, "standard_charge_algorithm": "Re-evaluated: HLB.752841182; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 10,287.00, and; Pricing Extension - NM HB XR PRC - PH BCBS HMO STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11584.19, "10th_percentile": 11584.19, "90th_percentile": 11584.19, "count": "13", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 11584.19, "standard_charge_algorithm": "Re-evaluated: HLB.752841182; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 10,287.00, and; Pricing Extension - NM HB XR PRC - PH BCBS HMO STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11584.19, "10th_percentile": 11584.19, "90th_percentile": 11584.19, "count": "13", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 16401.65, "standard_charge_algorithm": "Re-evaluated: HLB.752841182; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1261, Rate: 14,565.00, and; Pricing Extension - NM HB XR PRC - PH BCBS PPO STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16401.65, "10th_percentile": 16401.65, "90th_percentile": 16401.65, "count": "13", "methodology": "case rate" } ] } ] }, { "description": "ALBUMIN 25% (0.25 G/ML) INJECTION FROM PREMIX (NICU)", "drug_information": { "unit": 50.0, "type": "ML" }, "code_information": [ { "code": "RX-40808981", "type": "CDM" }, { "code": "P9047", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "76125-0792-25", "type": "NDC" } ], "standard_charges": [ { "minimum": 29.04, "maximum": 181.5, "setting": "outpatient", "gross_charge": 181.5, "discounted_cash": 127.05, "payers_information": [ { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 181.5, "10th_percentile": 181.5, "90th_percentile": 181.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 181.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $181.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 181.5, "10th_percentile": 181.5, "90th_percentile": 181.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $181.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 39.02, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 39.02, "10th_percentile": 39.02, "90th_percentile": 39.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 145.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 145.2, "10th_percentile": 145.2, "90th_percentile": 145.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 136.13, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 136.13, "10th_percentile": 136.13, "90th_percentile": 136.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 90.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 90.75, "10th_percentile": 90.75, "90th_percentile": 90.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 181.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 181.5, "10th_percentile": 181.5, "90th_percentile": 181.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 145.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 145.2, "10th_percentile": 145.2, "90th_percentile": 145.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 90.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 90.75, "10th_percentile": 90.75, "90th_percentile": 90.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 136.13, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 136.13, "10th_percentile": 136.13, "90th_percentile": 136.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 108.9, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 108.9, "10th_percentile": 108.9, "90th_percentile": 108.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 61.53, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 61.53, "10th_percentile": 61.53, "90th_percentile": 61.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 154.28, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 154.28, "10th_percentile": 154.28, "90th_percentile": 154.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 127.05, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 127.05, "10th_percentile": 127.05, "90th_percentile": 127.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 34.85, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 34.85, "10th_percentile": 34.85, "90th_percentile": 34.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 34.85, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 34.85, "10th_percentile": 34.85, "90th_percentile": 34.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 71.02, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 71.02, "10th_percentile": 71.02, "90th_percentile": 71.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 71.02, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 71.02, "10th_percentile": 71.02, "90th_percentile": 71.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 29.04, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 29.04, "10th_percentile": 29.04, "90th_percentile": 29.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 29.04, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 29.04, "10th_percentile": 29.04, "90th_percentile": 29.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 29.04, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 29.04, "10th_percentile": 29.04, "90th_percentile": 29.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 181.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 181.5, "10th_percentile": 181.5, "90th_percentile": 181.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 181.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 181.5, "10th_percentile": 181.5, "90th_percentile": 181.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 181.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 181.5, "10th_percentile": 181.5, "90th_percentile": 181.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 181.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 181.5, "10th_percentile": 181.5, "90th_percentile": 181.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 181.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 181.5, "10th_percentile": 181.5, "90th_percentile": 181.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 181.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 181.5, "10th_percentile": 181.5, "90th_percentile": 181.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 181.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 181.5, "10th_percentile": 181.5, "90th_percentile": 181.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 181.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 181.5, "10th_percentile": 181.5, "90th_percentile": 181.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 26.54, "10th_percentile": 26.54, "90th_percentile": 26.54, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 26.54, "10th_percentile": 26.54, "90th_percentile": 26.54, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "ALBUTEROL SULFATE 2.5 MG /3 ML (0.083 %) INH NEBU", "drug_information": { "unit": 3.0, "type": "ML" }, "code_information": [ { "code": "RX-250", "type": "CDM" }, { "code": "J3490", "type": "HCPCS" }, { "code": "0250", "type": "RC" }, { "code": "00487-9501-25", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.24, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1.75, "10th_percentile": 1.55, "90th_percentile": 1.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1.75, "10th_percentile": 1.55, "90th_percentile": 1.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1.75, "10th_percentile": 1.55, "90th_percentile": 1.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1.75, "10th_percentile": 1.55, "90th_percentile": 1.95, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1.75, "10th_percentile": 1.55, "90th_percentile": 1.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1.75, "10th_percentile": 1.55, "90th_percentile": 1.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1.75, "10th_percentile": 1.55, "90th_percentile": 1.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1.75, "10th_percentile": 1.55, "90th_percentile": 1.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1.75, "10th_percentile": 1.55, "90th_percentile": 1.95, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1.75, "10th_percentile": 1.55, "90th_percentile": 1.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1.75, "10th_percentile": 1.55, "90th_percentile": 1.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.32, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.28, "10th_percentile": 0.25, "90th_percentile": 0.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.69, "10th_percentile": 0.61, "90th_percentile": 0.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.38, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.33, "10th_percentile": 0.3, "90th_percentile": 0.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.88, "10th_percentile": 0.78, "90th_percentile": 0.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.4, "10th_percentile": 1.24, "90th_percentile": 1.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1.31, "10th_percentile": 1.17, "90th_percentile": 1.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.99, "10th_percentile": 0.88, "90th_percentile": 1.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1.31, "10th_percentile": 1.17, "90th_percentile": 1.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1.7, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1.49, "10th_percentile": 1.32, "90th_percentile": 1.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 0.88, "10th_percentile": 0.78, "90th_percentile": 0.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1.2, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1.05, "10th_percentile": 0.93, "90th_percentile": 1.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1.23, "10th_percentile": 1.08, "90th_percentile": 1.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1.28, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1.12, "10th_percentile": 0.99, "90th_percentile": 1.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1.02, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.9, "10th_percentile": 0.8, "90th_percentile": 0.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 0.91, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.8, "10th_percentile": 0.7, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.99, "10th_percentile": 0.88, "90th_percentile": 1.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.59, "10th_percentile": 0.53, "90th_percentile": 0.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.43, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.38, "10th_percentile": 0.33, "90th_percentile": 0.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1.75, "10th_percentile": 1.55, "90th_percentile": 1.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1.75, "10th_percentile": 1.55, "90th_percentile": 1.95, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.69, "10th_percentile": 0.61, "90th_percentile": 0.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.38, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.33, "10th_percentile": 0.3, "90th_percentile": 0.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1.4, "10th_percentile": 1.24, "90th_percentile": 1.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.32, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.28, "10th_percentile": 0.25, "90th_percentile": 0.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.32, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.28, "10th_percentile": 0.25, "90th_percentile": 0.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "ALBUTEROL SULFATE 2.5 MG /3 ML (0.083 %) INH NEBU|DISCARDED DRUG NOT ADMINISTE", "drug_information": { "unit": 1.5, "type": "ML" }, "code_information": [ { "code": "RX-250", "type": "CDM" }, { "code": "J3490", "type": "HCPCS" }, { "code": "0250", "type": "RC" }, { "code": "00378-8270-62", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.12, "maximum": 2.0, "setting": "outpatient", "gross_charge": 0.75, "discounted_cash": 0.52, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 0.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1.38, "10th_percentile": 0.88, "90th_percentile": 1.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 0.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1.38, "10th_percentile": 0.88, "90th_percentile": 1.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 0.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1.38, "10th_percentile": 0.88, "90th_percentile": 1.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 0.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1.38, "10th_percentile": 0.88, "90th_percentile": 1.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 0.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1.38, "10th_percentile": 0.88, "90th_percentile": 1.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 0.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1.38, "10th_percentile": 0.88, "90th_percentile": 1.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 0.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1.38, "10th_percentile": 0.88, "90th_percentile": 1.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 0.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1.38, "10th_percentile": 0.88, "90th_percentile": 1.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 0.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1.38, "10th_percentile": 0.88, "90th_percentile": 1.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 0.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $0.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1.38, "10th_percentile": 0.88, "90th_percentile": 1.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $0.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1.38, "10th_percentile": 0.88, "90th_percentile": 1.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1.38, "10th_percentile": 0.88, "90th_percentile": 1.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1.38, "10th_percentile": 0.88, "90th_percentile": 1.88, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 0.34, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.63, "10th_percentile": 0.4, "90th_percentile": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 0.43, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.5, "90th_percentile": 1.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.25, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.47, "10th_percentile": 0.29, "90th_percentile": 0.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.16, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.29, "10th_percentile": 0.19, "90th_percentile": 0.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.29, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.54, "10th_percentile": 0.34, "90th_percentile": 0.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.14, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.26, "10th_percentile": 0.16, "90th_percentile": 0.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 0.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1.1, "10th_percentile": 0.7, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.12, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.22, "10th_percentile": 0.14, "90th_percentile": 0.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.12, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.22, "10th_percentile": 0.14, "90th_percentile": 0.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.12, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.22, "10th_percentile": 0.14, "90th_percentile": 0.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.29, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.54, "10th_percentile": 0.34, "90th_percentile": 0.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.14, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.26, "10th_percentile": 0.16, "90th_percentile": 0.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 0.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.69, "10th_percentile": 0.44, "90th_percentile": 0.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 0.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.1, "10th_percentile": 0.7, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 0.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1.03, "10th_percentile": 0.65, "90th_percentile": 1.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 0.43, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.5, "90th_percentile": 1.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 0.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1.03, "10th_percentile": 0.65, "90th_percentile": 1.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 0.64, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1.17, "10th_percentile": 0.75, "90th_percentile": 1.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 0.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 0.69, "10th_percentile": 0.44, "90th_percentile": 0.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 0.45, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 0.82, "10th_percentile": 0.53, "90th_percentile": 1.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 0.53, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 0.96, "10th_percentile": 0.62, "90th_percentile": 1.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 0.48, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 0.88, "10th_percentile": 0.56, "90th_percentile": 1.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 0.38, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.7, "10th_percentile": 0.44, "90th_percentile": 0.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "ALBUTEROL SULFATE 2.5 MG /3 ML (0.083 %) INH NEBU|DISCARDED DRUG NOT ADMINISTE", "drug_information": { "unit": 1.5, "type": "ML" }, "code_information": [ { "code": "RX-250", "type": "CDM" }, { "code": "J3490", "type": "HCPCS" }, { "code": "0250", "type": "RC" }, { "code": "00378-8270-93", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.12, "maximum": 2.0, "setting": "outpatient", "gross_charge": 0.75, "discounted_cash": 0.52, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 0.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1.38, "10th_percentile": 0.88, "90th_percentile": 1.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 0.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1.38, "10th_percentile": 0.88, "90th_percentile": 1.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 0.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1.38, "10th_percentile": 0.88, "90th_percentile": 1.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 0.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1.38, "10th_percentile": 0.88, "90th_percentile": 1.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 0.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1.38, "10th_percentile": 0.88, "90th_percentile": 1.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 0.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1.38, "10th_percentile": 0.88, "90th_percentile": 1.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 0.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $0.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1.38, "10th_percentile": 0.88, "90th_percentile": 1.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $0.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1.38, "10th_percentile": 0.88, "90th_percentile": 1.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1.38, "10th_percentile": 0.88, "90th_percentile": 1.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 0.43, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.5, "90th_percentile": 1.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.25, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.47, "10th_percentile": 0.29, "90th_percentile": 0.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.16, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.29, "10th_percentile": 0.19, "90th_percentile": 0.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.29, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.54, "10th_percentile": 0.34, "90th_percentile": 0.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.14, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.26, "10th_percentile": 0.16, "90th_percentile": 0.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 0.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1.1, "10th_percentile": 0.7, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.12, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.22, "10th_percentile": 0.14, "90th_percentile": 0.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.12, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.22, "10th_percentile": 0.14, "90th_percentile": 0.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.12, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.22, "10th_percentile": 0.14, "90th_percentile": 0.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.29, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.54, "10th_percentile": 0.34, "90th_percentile": 0.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.14, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.26, "10th_percentile": 0.16, "90th_percentile": 0.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 0.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.69, "10th_percentile": 0.44, "90th_percentile": 0.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 0.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.1, "10th_percentile": 0.7, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 0.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1.03, "10th_percentile": 0.65, "90th_percentile": 1.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 0.43, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.5, "90th_percentile": 1.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 0.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1.03, "10th_percentile": 0.65, "90th_percentile": 1.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 0.64, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1.17, "10th_percentile": 0.75, "90th_percentile": 1.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 0.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 0.69, "10th_percentile": 0.44, "90th_percentile": 0.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 0.45, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 0.82, "10th_percentile": 0.53, "90th_percentile": 1.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 0.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1.38, "10th_percentile": 0.88, "90th_percentile": 1.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 0.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1.38, "10th_percentile": 0.88, "90th_percentile": 1.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 0.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1.38, "10th_percentile": 0.88, "90th_percentile": 1.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1.38, "10th_percentile": 0.88, "90th_percentile": 1.88, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 0.53, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 0.96, "10th_percentile": 0.62, "90th_percentile": 1.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 0.48, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 0.88, "10th_percentile": 0.56, "90th_percentile": 1.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 0.38, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.7, "10th_percentile": 0.44, "90th_percentile": 0.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 0.34, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.63, "10th_percentile": 0.4, "90th_percentile": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "ALBUTEROL SULFATE 2.5 MG/0.5 ML INH NEBU", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-97580", "type": "CDM" }, { "code": "25000000", "type": "LOCAL" }, { "code": "0250", "type": "RC" }, { "code": "00487-9901-30", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.38, "maximum": 2.75, "setting": "outpatient", "gross_charge": 2.75, "discounted_cash": 1.92, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.56, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.56, "10th_percentile": 1.56, "90th_percentile": 1.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.93, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.93, "10th_percentile": 0.93, "90th_percentile": 0.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.59, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.59, "10th_percentile": 0.59, "90th_percentile": 0.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1.08, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.08, "10th_percentile": 1.08, "90th_percentile": 1.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1.22, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.22, "10th_percentile": 1.22, "90th_percentile": 1.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 2.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 2.2, "10th_percentile": 2.2, "90th_percentile": 2.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.47, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.47, "10th_percentile": 0.47, "90th_percentile": 0.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.38, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.38, "10th_percentile": 0.38, "90th_percentile": 0.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.39, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.39, "10th_percentile": 0.39, "90th_percentile": 0.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1.08, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.08, "10th_percentile": 1.08, "90th_percentile": 1.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1.22, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.22, "10th_percentile": 1.22, "90th_percentile": 1.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.38, "10th_percentile": 1.38, "90th_percentile": 1.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.51, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.51, "10th_percentile": 0.51, "90th_percentile": 0.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 2.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.2, "10th_percentile": 2.2, "90th_percentile": 2.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 0.81, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.81, "10th_percentile": 0.81, "90th_percentile": 0.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 2.06, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 2.06, "10th_percentile": 2.06, "90th_percentile": 2.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.56, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.56, "10th_percentile": 1.56, "90th_percentile": 1.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 2.06, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 2.06, "10th_percentile": 2.06, "90th_percentile": 2.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 2.34, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 2.34, "10th_percentile": 2.34, "90th_percentile": 2.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.38, "10th_percentile": 1.38, "90th_percentile": 1.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1.65, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1.65, "10th_percentile": 1.65, "90th_percentile": 1.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1.93, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1.93, "10th_percentile": 1.93, "90th_percentile": 1.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1.77, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1.77, "10th_percentile": 1.77, "90th_percentile": 1.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1.41, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.41, "10th_percentile": 1.41, "90th_percentile": 1.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 1.25, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.25, "10th_percentile": 1.25, "90th_percentile": 1.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "ALBUTEROL SULFATE 2.5 MG/0.5 ML INH NEBU", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-97580", "type": "CDM" }, { "code": "25000000", "type": "LOCAL" }, { "code": "0250", "type": "RC" }, { "code": "76204-0027-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.38, "maximum": 2.75, "setting": "outpatient", "gross_charge": 2.75, "discounted_cash": 1.92, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.56, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.56, "10th_percentile": 1.56, "90th_percentile": 1.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.93, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.93, "10th_percentile": 0.93, "90th_percentile": 0.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.59, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.59, "10th_percentile": 0.59, "90th_percentile": 0.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1.08, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.08, "10th_percentile": 1.08, "90th_percentile": 1.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1.22, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.22, "10th_percentile": 1.22, "90th_percentile": 1.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 2.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 2.2, "10th_percentile": 2.2, "90th_percentile": 2.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.47, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.47, "10th_percentile": 0.47, "90th_percentile": 0.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.38, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.38, "10th_percentile": 0.38, "90th_percentile": 0.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.39, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.39, "10th_percentile": 0.39, "90th_percentile": 0.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1.08, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.08, "10th_percentile": 1.08, "90th_percentile": 1.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1.22, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.22, "10th_percentile": 1.22, "90th_percentile": 1.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.38, "10th_percentile": 1.38, "90th_percentile": 1.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.51, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.51, "10th_percentile": 0.51, "90th_percentile": 0.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 2.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.2, "10th_percentile": 2.2, "90th_percentile": 2.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 0.81, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.81, "10th_percentile": 0.81, "90th_percentile": 0.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 2.06, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 2.06, "10th_percentile": 2.06, "90th_percentile": 2.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.56, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.56, "10th_percentile": 1.56, "90th_percentile": 1.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 2.06, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 2.06, "10th_percentile": 2.06, "90th_percentile": 2.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 2.34, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 2.34, "10th_percentile": 2.34, "90th_percentile": 2.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.38, "10th_percentile": 1.38, "90th_percentile": 1.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1.65, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1.65, "10th_percentile": 1.65, "90th_percentile": 1.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1.93, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1.93, "10th_percentile": 1.93, "90th_percentile": 1.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1.77, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1.77, "10th_percentile": 1.77, "90th_percentile": 1.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1.41, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.41, "10th_percentile": 1.41, "90th_percentile": 1.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 1.25, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.25, "10th_percentile": 1.25, "90th_percentile": 1.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "ALLERGIC REACTIONS WITH MCC", "code_information": [ { "code": "915", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 11965.98, "maximum": 24492.5, "setting": "inpatient", "gross_charge": 44877.5, "discounted_cash": 31414.25, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_dollar": 11965.98, "standard_charge_algorithm": "Re-evaluated: HLB.837759174; Using historical claim(s); Scope: All Financial Classes; Cases: 3; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.68, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $12,704.59; Additional payment reduction: $127.05; Total: $12,577.54", "median_amount": 12577.54, "10th_percentile": 12577.54, "90th_percentile": 12577.54, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.837759174; Using historical claim(s); Scope: All Financial Classes; Cases: 3; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.68, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $12,704.59; Additional payment reduction: $127.05; Total: $12,577.54" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_dollar": 11965.98, "standard_charge_algorithm": "Re-evaluated: HLB.837759174; Using historical claim(s); Scope: All Financial Classes; Cases: 3; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.68, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $12,704.59; Additional payment reduction: $127.05; Total: $12,577.54", "median_amount": 12577.54, "10th_percentile": 12577.54, "90th_percentile": 12577.54, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.837759174; Using historical claim(s); Scope: All Financial Classes; Cases: 3; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.68, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $12,704.59; Additional payment reduction: $127.05; Total: $12,577.54" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.837759174; Using historical claim(s); Scope: All Financial Classes; Cases: 3; All IP Services; 100% Billed", "median_amount": 44816.75, "10th_percentile": 44816.75, "90th_percentile": 44816.75, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.837759174; Using historical claim(s); Scope: All Financial Classes; Cases: 3; All IP Services; 100% Billed", "median_amount": 44816.75, "10th_percentile": 44816.75, "90th_percentile": 44816.75, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.837759174; Using historical claim(s); Scope: All Financial Classes; Cases: 3; All IP Services; 100% Billed", "median_amount": 44816.75, "10th_percentile": 44816.75, "90th_percentile": 44816.75, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.837759174; Using historical claim(s); Scope: All Financial Classes; Cases: 3; All IP Services; 100% Billed", "median_amount": 44816.75, "10th_percentile": 44816.75, "90th_percentile": 44816.75, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.837759174; Using historical claim(s); Scope: All Financial Classes; Cases: 3; All IP Services; 100% Billed", "median_amount": 44816.75, "10th_percentile": 44816.75, "90th_percentile": 44816.75, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.837759174; Using historical claim(s); Scope: All Financial Classes; Cases: 3; All IP Services; 100% Billed", "median_amount": 44816.75, "10th_percentile": 44816.75, "90th_percentile": 44816.75, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.837759174; Using historical claim(s); Scope: All Financial Classes; Cases: 3; All IP Services; 100% Billed", "median_amount": 44816.75, "10th_percentile": 44816.75, "90th_percentile": 44816.75, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Re-evaluated: HLB.837759174; Using historical claim(s); Scope: All Financial Classes; Cases: 3; Inpatient; 80% Billed", "median_amount": 35853.4, "10th_percentile": 35853.4, "90th_percentile": 35853.4, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 30.4, "standard_charge_algorithm": "Re-evaluated: HLB.837759174; Using historical claim(s); Scope: All Financial Classes; Cases: 3; IP Services. ADP RATE (for patient estimates only); 30.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13624.29, "10th_percentile": 13624.29, "90th_percentile": 13624.29, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_percentage": 21.5, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 9635.64, "10th_percentile": 9635.64, "90th_percentile": 9635.64, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_percentage": 34.2, "standard_charge_algorithm": "Re-evaluated: HLB.837759174; Using historical claim(s); Scope: All Financial Classes; Cases: 3; All Inpatient Services; 34.2% Billed", "median_amount": 15327.33, "10th_percentile": 15327.33, "90th_percentile": 15327.33, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Re-evaluated: HLB.837759174; Using historical claim(s); Scope: All Financial Classes; Cases: 3; Inpatient Services; 50% Billed", "median_amount": 22408.38, "10th_percentile": 22408.38, "90th_percentile": 22408.38, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional drugs, imaging services, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 22408.38, "10th_percentile": 22408.38, "90th_percentile": 22408.38, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Re-evaluated: HLB.837759174; Using historical claim(s); Scope: All Financial Classes; Cases: 3; STOP LOSS; 75% Billed", "median_amount": 33612.56, "10th_percentile": 33612.56, "90th_percentile": 33612.56, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Re-evaluated: HLB.837759174; Using historical claim(s); Scope: All Financial Classes; Cases: 3; All IP Services; 75% Billed", "median_amount": 33612.56, "10th_percentile": 33612.56, "90th_percentile": 33612.56, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 24492.5, "standard_charge_algorithm": "Re-evaluated: HLB.837759174; Using historical claim(s); Scope: All Financial Classes; Cases: 3; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.6816, Rate: 14,565.00, and; Pricing Extension - NM HB XR PRC - PH BCBS PPO STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24492.5, "10th_percentile": 24492.5, "90th_percentile": 24492.5, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 17298.62, "standard_charge_algorithm": "Re-evaluated: HLB.837759174; Using historical claim(s); Scope: All Financial Classes; Cases: 3; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.6816, Rate: 10,287.00, and; Pricing Extension - NM HB XR PRC - PH BCBS HMO STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17298.62, "10th_percentile": 17298.62, "90th_percentile": 17298.62, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 17298.62, "standard_charge_algorithm": "Re-evaluated: HLB.837759174; Using historical claim(s); Scope: All Financial Classes; Cases: 3; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.6816, Rate: 10,287.00, and; Pricing Extension - NM HB XR PRC - PH BCBS HMO STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17298.62, "10th_percentile": 17298.62, "90th_percentile": 17298.62, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 24492.5, "standard_charge_algorithm": "Re-evaluated: HLB.837759174; Using historical claim(s); Scope: All Financial Classes; Cases: 3; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.6816, Rate: 14,565.00, and; Pricing Extension - NM HB XR PRC - PH BCBS PPO STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24492.5, "10th_percentile": 24492.5, "90th_percentile": 24492.5, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 15210.07, "standard_charge_algorithm": "Re-evaluated: HLB.837759174; Using historical claim(s); Scope: All Financial Classes; Cases: 3; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.6816, Rate: 9,045.00, and; Pricing Extension - NM HB XR PRC - PH BCBS CHOICE STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15210.07, "10th_percentile": 15210.07, "90th_percentile": 15210.07, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 13461.21, "standard_charge_algorithm": "Re-evaluated: HLB.837759174; Using historical claim(s); Scope: All Financial Classes; Cases: 3; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.6816, Rate: 8,005.00, and; Pricing Extension - NM HB XR PRC - PH BCBS CHOICE SELECT STOP LOSS & LESSOR OF *; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13461.21, "10th_percentile": 13461.21, "90th_percentile": 13461.21, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 14402.9, "standard_charge_algorithm": "Re-evaluated: HLB.837759174; Using historical claim(s); Scope: All Financial Classes; Cases: 3; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.6816, Rate: 8,565.00, and; Pricing Extension - NM HB XR PRC - PH BCBS CHOICE PREF STOP LOSS & LESSOR OF 9.*; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14402.9, "10th_percentile": 14402.9, "90th_percentile": 14402.9, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.837759174; Using historical claim(s); Scope: All Financial Classes; Cases: 3; All IP Services - OON; 100% Billed", "median_amount": 44816.75, "10th_percentile": 44816.75, "90th_percentile": 44816.75, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.837759174; Using historical claim(s); Scope: All Financial Classes; Cases: 3; All IP Services; 100% Billed", "median_amount": 44816.75, "10th_percentile": 44816.75, "90th_percentile": 44816.75, "count": "1 through 10", "methodology": "percent of total billed charges" } ] } ] }, { "description": "ALLOPURINOL 100 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-310", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "16729-0134-16", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.89, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.89, "10th_percentile": 0.89, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.89, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.89, "10th_percentile": 0.89, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1.7, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1.7, "10th_percentile": 1.7, "90th_percentile": 1.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1.2, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1.2, "10th_percentile": 1.2, "90th_percentile": 1.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1.28, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1.28, "10th_percentile": 1.28, "90th_percentile": 1.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1.4, "10th_percentile": 1.4, "90th_percentile": 1.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.29, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.29, "10th_percentile": 0.29, "90th_percentile": 0.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 0.91, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.91, "10th_percentile": 0.91, "90th_percentile": 0.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1.02, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.02, "10th_percentile": 1.02, "90th_percentile": 1.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.59, "10th_percentile": 0.59, "90th_percentile": 0.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.28, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.28, "10th_percentile": 0.28, "90th_percentile": 0.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.37, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.37, "10th_percentile": 0.37, "90th_percentile": 0.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.68, "10th_percentile": 0.68, "90th_percentile": 0.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.43, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.34, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.34, "10th_percentile": 0.34, "90th_percentile": 0.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "ALLOPURINOL 100 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-310", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "29300-0349-05", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.89, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.89, "10th_percentile": 0.89, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.89, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.89, "10th_percentile": 0.89, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1.7, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1.7, "10th_percentile": 1.7, "90th_percentile": 1.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1.2, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1.2, "10th_percentile": 1.2, "90th_percentile": 1.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1.28, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1.28, "10th_percentile": 1.28, "90th_percentile": 1.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1.4, "10th_percentile": 1.4, "90th_percentile": 1.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.29, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.29, "10th_percentile": 0.29, "90th_percentile": 0.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 0.91, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.91, "10th_percentile": 0.91, "90th_percentile": 0.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1.02, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.02, "10th_percentile": 1.02, "90th_percentile": 1.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.59, "10th_percentile": 0.59, "90th_percentile": 0.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.28, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.28, "10th_percentile": 0.28, "90th_percentile": 0.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.37, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.37, "10th_percentile": 0.37, "90th_percentile": 0.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.68, "10th_percentile": 0.68, "90th_percentile": 0.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.43, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.34, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.34, "10th_percentile": 0.34, "90th_percentile": 0.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "ALPRAZOLAM 0.25 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-324", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "60687-0377-11", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.89, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.89, "10th_percentile": 0.89, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.89, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.89, "10th_percentile": 0.89, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1.4, "10th_percentile": 1.4, "90th_percentile": 1.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.43, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.37, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.37, "10th_percentile": 0.37, "90th_percentile": 0.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1.2, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1.2, "10th_percentile": 1.2, "90th_percentile": 1.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.68, "10th_percentile": 0.68, "90th_percentile": 0.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.28, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.28, "10th_percentile": 0.28, "90th_percentile": 0.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1.7, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1.7, "10th_percentile": 1.7, "90th_percentile": 1.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.29, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.29, "10th_percentile": 0.29, "90th_percentile": 0.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.34, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.34, "10th_percentile": 0.34, "90th_percentile": 0.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.59, "10th_percentile": 0.59, "90th_percentile": 0.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1.28, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1.28, "10th_percentile": 1.28, "90th_percentile": 1.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 0.91, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.91, "10th_percentile": 0.91, "90th_percentile": 0.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1.02, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.02, "10th_percentile": 1.02, "90th_percentile": 1.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "ALPRAZOLAM 0.5 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-325", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "65862-0677-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.89, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.89, "10th_percentile": 0.89, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.89, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.89, "10th_percentile": 0.89, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1.7, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1.7, "10th_percentile": 1.7, "90th_percentile": 1.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1.2, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1.2, "10th_percentile": 1.2, "90th_percentile": 1.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1.28, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1.28, "10th_percentile": 1.28, "90th_percentile": 1.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1.4, "10th_percentile": 1.4, "90th_percentile": 1.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.29, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.29, "10th_percentile": 0.29, "90th_percentile": 0.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 0.91, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.91, "10th_percentile": 0.91, "90th_percentile": 0.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1.02, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.02, "10th_percentile": 1.02, "90th_percentile": 1.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.59, "10th_percentile": 0.59, "90th_percentile": 0.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.28, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.28, "10th_percentile": 0.28, "90th_percentile": 0.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.37, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.37, "10th_percentile": 0.37, "90th_percentile": 0.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.68, "10th_percentile": 0.68, "90th_percentile": 0.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.43, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.34, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.34, "10th_percentile": 0.34, "90th_percentile": 0.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "AMINOPHYLLINE 500 MG/20 ML IV SOLN", "drug_information": { "unit": 20.0, "type": "ML" }, "code_information": [ { "code": "RX-93458", "type": "CDM" }, { "code": "J0280", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "00409-5922-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 10.4, "maximum": 65.0, "setting": "outpatient", "gross_charge": 65.0, "discounted_cash": 45.5, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 65.0, "10th_percentile": 65.0, "90th_percentile": 65.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 65.0, "10th_percentile": 65.0, "90th_percentile": 65.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 65.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $65.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 65.0, "10th_percentile": 65.0, "90th_percentile": 65.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $65.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 52.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 52.0, "10th_percentile": 52.0, "90th_percentile": 52.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 48.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 48.75, "10th_percentile": 48.75, "90th_percentile": 48.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 32.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 32.5, "10th_percentile": 32.5, "90th_percentile": 32.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 65.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 65.0, "10th_percentile": 65.0, "90th_percentile": 65.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 52.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 52.0, "10th_percentile": 52.0, "90th_percentile": 52.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 32.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 32.5, "10th_percentile": 32.5, "90th_percentile": 32.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 48.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 48.75, "10th_percentile": 48.75, "90th_percentile": 48.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 39.0, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 39.0, "10th_percentile": 39.0, "90th_percentile": 39.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 55.25, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 55.25, "10th_percentile": 55.25, "90th_percentile": 55.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 45.5, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 45.5, "10th_percentile": 45.5, "90th_percentile": 45.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 12.48, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.48, "10th_percentile": 12.48, "90th_percentile": 12.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 12.48, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.48, "10th_percentile": 12.48, "90th_percentile": 12.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 25.43, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.43, "10th_percentile": 25.43, "90th_percentile": 25.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 25.43, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.43, "10th_percentile": 25.43, "90th_percentile": 25.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 10.4, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.4, "10th_percentile": 10.4, "90th_percentile": 10.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 10.4, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.4, "10th_percentile": 10.4, "90th_percentile": 10.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 10.4, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.4, "10th_percentile": 10.4, "90th_percentile": 10.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 65.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 65.0, "10th_percentile": 65.0, "90th_percentile": 65.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 65.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 65.0, "10th_percentile": 65.0, "90th_percentile": 65.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 65.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 65.0, "10th_percentile": 65.0, "90th_percentile": 65.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 65.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 65.0, "10th_percentile": 65.0, "90th_percentile": 65.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 65.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 65.0, "10th_percentile": 65.0, "90th_percentile": 65.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 65.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 65.0, "10th_percentile": 65.0, "90th_percentile": 65.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 65.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 65.0, "10th_percentile": 65.0, "90th_percentile": 65.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 65.0, "10th_percentile": 65.0, "90th_percentile": 65.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 13.98, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 13.98, "10th_percentile": 13.98, "90th_percentile": 13.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 22.04, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 22.04, "10th_percentile": 22.04, "90th_percentile": 22.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 65.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 65.0, "10th_percentile": 65.0, "90th_percentile": 65.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "AMIODARONE 200 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-9066", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "65862-0732-05", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.89, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.89, "10th_percentile": 0.89, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.89, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.89, "10th_percentile": 0.89, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1.7, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1.7, "10th_percentile": 1.7, "90th_percentile": 1.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1.2, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1.2, "10th_percentile": 1.2, "90th_percentile": 1.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1.28, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1.28, "10th_percentile": 1.28, "90th_percentile": 1.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1.4, "10th_percentile": 1.4, "90th_percentile": 1.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.29, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.29, "10th_percentile": 0.29, "90th_percentile": 0.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 0.91, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.91, "10th_percentile": 0.91, "90th_percentile": 0.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1.02, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.02, "10th_percentile": 1.02, "90th_percentile": 1.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.59, "10th_percentile": 0.59, "90th_percentile": 0.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.28, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.28, "10th_percentile": 0.28, "90th_percentile": 0.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.37, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.37, "10th_percentile": 0.37, "90th_percentile": 0.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.68, "10th_percentile": 0.68, "90th_percentile": 0.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.43, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.34, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.34, "10th_percentile": 0.34, "90th_percentile": 0.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "AMIODARONE 50 MG/ML IV SOLN", "drug_information": { "unit": 3.0, "type": "ML" }, "code_information": [ { "code": "RX-9065", "type": "CDM" }, { "code": "J0282", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "63323-0616-03", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.44, "maximum": 9.0, "setting": "outpatient", "gross_charge": 9.0, "discounted_cash": 6.3, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 9.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $9.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $9.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 7.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.2, "10th_percentile": 7.2, "90th_percentile": 7.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 6.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 6.75, "10th_percentile": 6.75, "90th_percentile": 6.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 7.65, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 7.65, "10th_percentile": 7.65, "90th_percentile": 7.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 6.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 6.75, "10th_percentile": 6.75, "90th_percentile": 6.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 9.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 5.4, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 5.4, "10th_percentile": 5.4, "90th_percentile": 5.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 6.3, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 6.3, "10th_percentile": 6.3, "90th_percentile": 6.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 4.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.5, "10th_percentile": 4.5, "90th_percentile": 4.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 4.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 4.5, "10th_percentile": 4.5, "90th_percentile": 4.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1.73, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.73, "10th_percentile": 1.73, "90th_percentile": 1.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 3.52, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.52, "10th_percentile": 3.52, "90th_percentile": 3.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.44, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.44, "10th_percentile": 1.44, "90th_percentile": 1.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 1.44, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.44, "10th_percentile": 1.44, "90th_percentile": 1.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 1.94, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 1.94, "10th_percentile": 1.94, "90th_percentile": 1.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 7.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 7.2, "10th_percentile": 7.2, "90th_percentile": 7.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 3.05, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 3.05, "10th_percentile": 3.05, "90th_percentile": 3.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1.73, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.73, "10th_percentile": 1.73, "90th_percentile": 1.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 3.52, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.52, "10th_percentile": 3.52, "90th_percentile": 3.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.44, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.44, "10th_percentile": 1.44, "90th_percentile": 1.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "AMIODARONE IN DEXTROSE,ISO-OSM 150 MG/100 ML (1.5 MG/ML) IV SOLN", "drug_information": { "unit": 100.0, "type": "ML" }, "code_information": [ { "code": "RX-191197", "type": "CDM" }, { "code": "J0283", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "43066-0150-10", "type": "NDC" } ], "standard_charges": [ { "minimum": 21.84, "maximum": 136.5, "setting": "outpatient", "gross_charge": 136.5, "discounted_cash": 95.55, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 136.5, "10th_percentile": 136.5, "90th_percentile": 136.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 136.5, "10th_percentile": 136.5, "90th_percentile": 136.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 136.5, "10th_percentile": 136.5, "90th_percentile": 136.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 136.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $136.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 136.5, "10th_percentile": 136.5, "90th_percentile": 136.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $136.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 29.35, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 29.35, "10th_percentile": 29.35, "90th_percentile": 29.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 109.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 109.2, "10th_percentile": 109.2, "90th_percentile": 109.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 102.38, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 102.38, "10th_percentile": 102.38, "90th_percentile": 102.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 68.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 68.25, "10th_percentile": 68.25, "90th_percentile": 68.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 136.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 136.5, "10th_percentile": 136.5, "90th_percentile": 136.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 109.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 109.2, "10th_percentile": 109.2, "90th_percentile": 109.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 68.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 68.25, "10th_percentile": 68.25, "90th_percentile": 68.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 102.38, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 102.38, "10th_percentile": 102.38, "90th_percentile": 102.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 81.9, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 81.9, "10th_percentile": 81.9, "90th_percentile": 81.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 46.27, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 46.27, "10th_percentile": 46.27, "90th_percentile": 46.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 116.03, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 116.03, "10th_percentile": 116.03, "90th_percentile": 116.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 95.55, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 95.55, "10th_percentile": 95.55, "90th_percentile": 95.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 26.21, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 26.21, "10th_percentile": 26.21, "90th_percentile": 26.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 26.21, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 26.21, "10th_percentile": 26.21, "90th_percentile": 26.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 53.41, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 53.41, "10th_percentile": 53.41, "90th_percentile": 53.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 53.41, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 53.41, "10th_percentile": 53.41, "90th_percentile": 53.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 21.84, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.84, "10th_percentile": 21.84, "90th_percentile": 21.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 21.84, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.84, "10th_percentile": 21.84, "90th_percentile": 21.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 21.84, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.84, "10th_percentile": 21.84, "90th_percentile": 21.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 136.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 136.5, "10th_percentile": 136.5, "90th_percentile": 136.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 136.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 136.5, "10th_percentile": 136.5, "90th_percentile": 136.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 136.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 136.5, "10th_percentile": 136.5, "90th_percentile": 136.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 136.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 136.5, "10th_percentile": 136.5, "90th_percentile": 136.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 136.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 136.5, "10th_percentile": 136.5, "90th_percentile": 136.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 136.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 136.5, "10th_percentile": 136.5, "90th_percentile": 136.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 136.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 136.5, "10th_percentile": 136.5, "90th_percentile": 136.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 136.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 136.5, "10th_percentile": 136.5, "90th_percentile": 136.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "AMITRIPTYLINE 10 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-432", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "29300-0419-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.89, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.89, "10th_percentile": 0.89, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1.7, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1.7, "10th_percentile": 1.7, "90th_percentile": 1.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1.2, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1.2, "10th_percentile": 1.2, "90th_percentile": 1.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1.28, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1.28, "10th_percentile": 1.28, "90th_percentile": 1.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1.4, "10th_percentile": 1.4, "90th_percentile": 1.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.29, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.29, "10th_percentile": 0.29, "90th_percentile": 0.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 0.91, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.91, "10th_percentile": 0.91, "90th_percentile": 0.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1.02, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.02, "10th_percentile": 1.02, "90th_percentile": 1.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.59, "10th_percentile": 0.59, "90th_percentile": 0.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.28, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.28, "10th_percentile": 0.28, "90th_percentile": 0.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.37, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.37, "10th_percentile": 0.37, "90th_percentile": 0.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.34, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.34, "10th_percentile": 0.34, "90th_percentile": 0.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.89, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.89, "10th_percentile": 0.89, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.43, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.68, "10th_percentile": 0.68, "90th_percentile": 0.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" } ] } ] }, { "description": "AMITRIPTYLINE 10 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-432", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "50268-0037-15", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.35, "maximum": 2.5, "setting": "outpatient", "gross_charge": 2.5, "discounted_cash": 1.75, "payers_information": [ { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 2.13, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 2.13, "10th_percentile": 2.13, "90th_percentile": 2.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 1.13, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.13, "10th_percentile": 1.13, "90th_percentile": 1.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1.28, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.28, "10th_percentile": 1.28, "90th_percentile": 1.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1.5, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1.61, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1.61, "10th_percentile": 1.61, "90th_percentile": 1.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 0.74, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.74, "10th_percentile": 0.74, "90th_percentile": 0.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1.11, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.11, "10th_percentile": 1.11, "90th_percentile": 1.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.98, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.98, "10th_percentile": 0.98, "90th_percentile": 0.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.85, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.85, "10th_percentile": 0.85, "90th_percentile": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.54, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.54, "10th_percentile": 0.54, "90th_percentile": 0.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1.75, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1.75, "10th_percentile": 1.75, "90th_percentile": 1.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.47, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.47, "10th_percentile": 0.47, "90th_percentile": 0.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.25, "10th_percentile": 1.25, "90th_percentile": 1.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.25, "10th_percentile": 1.25, "90th_percentile": 1.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1.88, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1.88, "10th_percentile": 1.88, "90th_percentile": 1.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1.88, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1.88, "10th_percentile": 1.88, "90th_percentile": 1.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 2.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.42, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.42, "10th_percentile": 1.42, "90th_percentile": 1.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.42, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.42, "10th_percentile": 1.42, "90th_percentile": 1.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.35, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.35, "10th_percentile": 0.35, "90th_percentile": 0.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.98, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.98, "10th_percentile": 0.98, "90th_percentile": 0.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.36, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.36, "10th_percentile": 0.36, "90th_percentile": 0.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.42, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.42, "10th_percentile": 0.42, "90th_percentile": 0.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1.11, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.11, "10th_percentile": 1.11, "90th_percentile": 1.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "AMITRIPTYLINE 75 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-437", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "51079-0147-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.66, "maximum": 4.75, "setting": "outpatient", "gross_charge": 4.75, "discounted_cash": 3.32, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 1.02, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 1.02, "10th_percentile": 1.02, "90th_percentile": 1.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 1.61, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 1.61, "10th_percentile": 1.61, "90th_percentile": 1.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1.86, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.86, "10th_percentile": 1.86, "90th_percentile": 1.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 3.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 3.56, "10th_percentile": 3.56, "90th_percentile": 3.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 3.05, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 3.05, "10th_percentile": 3.05, "90th_percentile": 3.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 3.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.8, "10th_percentile": 3.8, "90th_percentile": 3.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 2.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 2.38, "10th_percentile": 2.38, "90th_percentile": 2.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.89, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.89, "10th_percentile": 0.89, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 3.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 3.56, "10th_percentile": 3.56, "90th_percentile": 3.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 3.33, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 3.33, "10th_percentile": 3.33, "90th_percentile": 3.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 2.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.38, "10th_percentile": 2.38, "90th_percentile": 2.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 4.04, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 4.04, "10th_percentile": 4.04, "90th_percentile": 4.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 1.41, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.41, "10th_percentile": 1.41, "90th_percentile": 1.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 2.85, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 2.85, "10th_percentile": 2.85, "90th_percentile": 2.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 2.1, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.1, "10th_percentile": 2.1, "90th_percentile": 2.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 2.43, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.43, "10th_percentile": 2.43, "90th_percentile": 2.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 4.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 4.75, "10th_percentile": 4.75, "90th_percentile": 4.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 2.15, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.15, "10th_percentile": 2.15, "90th_percentile": 2.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 3.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 3.8, "10th_percentile": 3.8, "90th_percentile": 3.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 2.7, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.7, "10th_percentile": 2.7, "90th_percentile": 2.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 2.7, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.7, "10th_percentile": 2.7, "90th_percentile": 2.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 4.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $4.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 4.75, "10th_percentile": 4.75, "90th_percentile": 4.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $4.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.66, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.66, "10th_percentile": 0.66, "90th_percentile": 0.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1.86, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.86, "10th_percentile": 1.86, "90th_percentile": 1.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.68, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.68, "10th_percentile": 0.68, "90th_percentile": 0.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.8, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.8, "10th_percentile": 0.8, "90th_percentile": 0.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 2.1, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.1, "10th_percentile": 2.1, "90th_percentile": 2.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4.75, "10th_percentile": 4.75, "90th_percentile": 4.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4.75, "10th_percentile": 4.75, "90th_percentile": 4.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 4.75, "10th_percentile": 4.75, "90th_percentile": 4.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4.75, "10th_percentile": 4.75, "90th_percentile": 4.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4.75, "10th_percentile": 4.75, "90th_percentile": 4.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4.75, "10th_percentile": 4.75, "90th_percentile": 4.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4.75, "10th_percentile": 4.75, "90th_percentile": 4.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4.75, "10th_percentile": 4.75, "90th_percentile": 4.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4.75, "10th_percentile": 4.75, "90th_percentile": 4.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4.75, "10th_percentile": 4.75, "90th_percentile": 4.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4.75, "10th_percentile": 4.75, "90th_percentile": 4.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "AMLODIPINE 10 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-9069", "type": "CDM" }, { "code": "J3490", "type": "HCPCS" }, { "code": "0637", "type": "RC" }, { "code": "67877-0199-05", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.32, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1.4, "10th_percentile": 1.4, "90th_percentile": 1.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1.2, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1.2, "10th_percentile": 1.2, "90th_percentile": 1.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1.02, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.02, "10th_percentile": 1.02, "90th_percentile": 1.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1.28, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1.28, "10th_percentile": 1.28, "90th_percentile": 1.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1.7, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1.7, "10th_percentile": 1.7, "90th_percentile": 1.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 0.91, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.91, "10th_percentile": 0.91, "90th_percentile": 0.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.43, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.68, "10th_percentile": 0.68, "90th_percentile": 0.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.38, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.38, "10th_percentile": 0.38, "90th_percentile": 0.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.38, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.38, "10th_percentile": 0.38, "90th_percentile": 0.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.32, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.32, "10th_percentile": 0.32, "90th_percentile": 0.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.32, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.32, "10th_percentile": 0.32, "90th_percentile": 0.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.32, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.32, "10th_percentile": 0.32, "90th_percentile": 0.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "AMMONIUM LACTATE 12 % TOP LOTN", "drug_information": { "unit": 225.0, "type": "GR" }, "code_information": [ { "code": "RX-10380", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "45802-0525-55", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.69, "maximum": 55.0, "setting": "outpatient", "gross_charge": 55.0, "discounted_cash": 38.5, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 55.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 55.0, "10th_percentile": 55.0, "90th_percentile": 55.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 55.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 55.0, "10th_percentile": 55.0, "90th_percentile": 55.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 55.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 55.0, "10th_percentile": 55.0, "90th_percentile": 55.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 55.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 55.0, "10th_percentile": 55.0, "90th_percentile": 55.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 55.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 55.0, "10th_percentile": 55.0, "90th_percentile": 55.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 55.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 55.0, "10th_percentile": 55.0, "90th_percentile": 55.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 55.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 55.0, "10th_percentile": 55.0, "90th_percentile": 55.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 55.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 55.0, "10th_percentile": 55.0, "90th_percentile": 55.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 31.24, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 31.24, "10th_percentile": 31.24, "90th_percentile": 31.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 31.24, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 31.24, "10th_percentile": 31.24, "90th_percentile": 31.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 21.52, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.52, "10th_percentile": 21.52, "90th_percentile": 21.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 21.52, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.52, "10th_percentile": 21.52, "90th_percentile": 21.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 24.35, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.35, "10th_percentile": 24.35, "90th_percentile": 24.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 24.35, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.35, "10th_percentile": 24.35, "90th_percentile": 24.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 55.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $55.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 55.0, "10th_percentile": 55.0, "90th_percentile": 55.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $55.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 9.31, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.31, "10th_percentile": 9.31, "90th_percentile": 9.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 7.85, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.85, "10th_percentile": 7.85, "90th_percentile": 7.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 7.69, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.69, "10th_percentile": 7.69, "90th_percentile": 7.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 38.5, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 38.5, "10th_percentile": 38.5, "90th_percentile": 38.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 24.92, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.92, "10th_percentile": 24.92, "90th_percentile": 24.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 55.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 55.0, "10th_percentile": 55.0, "90th_percentile": 55.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 28.11, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28.11, "10th_percentile": 28.11, "90th_percentile": 28.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 33.0, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 33.0, "10th_percentile": 33.0, "90th_percentile": 33.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 35.33, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 35.33, "10th_percentile": 35.33, "90th_percentile": 35.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 27.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 27.5, "10th_percentile": 27.5, "90th_percentile": 27.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 46.75, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 46.75, "10th_percentile": 46.75, "90th_percentile": 46.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 16.28, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.28, "10th_percentile": 16.28, "90th_percentile": 16.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 44.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 44.0, "10th_percentile": 44.0, "90th_percentile": 44.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 10.29, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.29, "10th_percentile": 10.29, "90th_percentile": 10.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 18.65, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 18.65, "10th_percentile": 18.65, "90th_percentile": 18.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 41.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 41.25, "10th_percentile": 41.25, "90th_percentile": 41.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 41.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 41.25, "10th_percentile": 41.25, "90th_percentile": 41.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 11.83, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 11.83, "10th_percentile": 11.83, "90th_percentile": 11.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 27.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 27.5, "10th_percentile": 27.5, "90th_percentile": 27.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 44.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 44.0, "10th_percentile": 44.0, "90th_percentile": 44.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 55.0, "10th_percentile": 55.0, "90th_percentile": 55.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 55.0, "10th_percentile": 55.0, "90th_percentile": 55.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 55.0, "10th_percentile": 55.0, "90th_percentile": 55.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "AMOXICILLIN-POT CLAVULANATE 200-28.5 MG/5 ML ORAL SUSR", "drug_information": { "unit": 12.5, "type": "ML" }, "code_information": [ { "code": "RX-33229", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "65862-0533-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.45, "maximum": 3.25, "setting": "outpatient", "gross_charge": 3.25, "discounted_cash": 2.27, "payers_information": [ { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3.25, "10th_percentile": 3.25, "90th_percentile": 3.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3.25, "10th_percentile": 3.25, "90th_percentile": 3.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3.25, "10th_percentile": 3.25, "90th_percentile": 3.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3.25, "10th_percentile": 3.25, "90th_percentile": 3.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3.25, "10th_percentile": 3.25, "90th_percentile": 3.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3.25, "10th_percentile": 3.25, "90th_percentile": 3.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3.25, "10th_percentile": 3.25, "90th_percentile": 3.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1.44, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.44, "10th_percentile": 1.44, "90th_percentile": 1.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.85, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.85, "10th_percentile": 1.85, "90th_percentile": 1.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1.27, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.27, "10th_percentile": 1.27, "90th_percentile": 1.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.63, "10th_percentile": 1.63, "90th_percentile": 1.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.61, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.61, "10th_percentile": 0.61, "90th_percentile": 0.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 2.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.6, "10th_percentile": 2.6, "90th_percentile": 2.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 0.96, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.96, "10th_percentile": 0.96, "90th_percentile": 0.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 2.44, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 2.44, "10th_percentile": 2.44, "90th_percentile": 2.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 2.44, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 2.44, "10th_percentile": 2.44, "90th_percentile": 2.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 2.76, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 2.76, "10th_percentile": 2.76, "90th_percentile": 2.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.63, "10th_percentile": 1.63, "90th_percentile": 1.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1.95, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1.95, "10th_percentile": 1.95, "90th_percentile": 1.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 2.28, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 2.28, "10th_percentile": 2.28, "90th_percentile": 2.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 2.09, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 2.09, "10th_percentile": 2.09, "90th_percentile": 2.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1.66, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.66, "10th_percentile": 1.66, "90th_percentile": 1.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 1.47, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.47, "10th_percentile": 1.47, "90th_percentile": 1.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 3.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 3.25, "10th_percentile": 3.25, "90th_percentile": 3.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.46, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.46, "10th_percentile": 0.46, "90th_percentile": 0.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3.25, "10th_percentile": 3.25, "90th_percentile": 3.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3.25, "10th_percentile": 3.25, "90th_percentile": 3.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 3.25, "10th_percentile": 3.25, "90th_percentile": 3.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3.25, "10th_percentile": 3.25, "90th_percentile": 3.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.7, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.7, "10th_percentile": 0.7, "90th_percentile": 0.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 1.1, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 1.1, "10th_percentile": 1.1, "90th_percentile": 1.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 2.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 2.6, "10th_percentile": 2.6, "90th_percentile": 2.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.45, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.45, "10th_percentile": 0.45, "90th_percentile": 0.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.55, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.55, "10th_percentile": 0.55, "90th_percentile": 0.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.85, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.85, "10th_percentile": 1.85, "90th_percentile": 1.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1.27, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.27, "10th_percentile": 1.27, "90th_percentile": 1.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1.44, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.44, "10th_percentile": 1.44, "90th_percentile": 1.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3.25, "10th_percentile": 3.25, "90th_percentile": 3.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "AMOXICILLIN-POT CLAVULANATE 500-125 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-33227", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "65862-0502-20", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.31, "maximum": 2.25, "setting": "outpatient", "gross_charge": 2.25, "discounted_cash": 1.57, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1.15, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.15, "10th_percentile": 1.15, "90th_percentile": 1.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 1.02, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.02, "10th_percentile": 1.02, "90th_percentile": 1.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1.45, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1.45, "10th_percentile": 1.45, "90th_percentile": 1.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.76, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.76, "10th_percentile": 0.76, "90th_percentile": 0.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1.91, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1.91, "10th_percentile": 1.91, "90th_percentile": 1.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1.35, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1.35, "10th_percentile": 1.35, "90th_percentile": 1.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.48, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.48, "10th_percentile": 0.48, "90th_percentile": 0.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1.0, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.88, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.88, "10th_percentile": 0.88, "90th_percentile": 0.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1.58, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1.58, "10th_percentile": 1.58, "90th_percentile": 1.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.42, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.42, "10th_percentile": 0.42, "90th_percentile": 0.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 0.67, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.67, "10th_percentile": 0.67, "90th_percentile": 0.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.13, "10th_percentile": 1.13, "90th_percentile": 1.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.13, "10th_percentile": 1.13, "90th_percentile": 1.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1.8, "10th_percentile": 1.8, "90th_percentile": 1.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.8, "10th_percentile": 1.8, "90th_percentile": 1.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1.69, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1.69, "10th_percentile": 1.69, "90th_percentile": 1.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1.69, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1.69, "10th_percentile": 1.69, "90th_percentile": 1.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.28, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.28, "10th_percentile": 1.28, "90th_percentile": 1.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.28, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.28, "10th_percentile": 1.28, "90th_percentile": 1.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.31, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.31, "10th_percentile": 0.31, "90th_percentile": 0.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.88, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.88, "10th_percentile": 0.88, "90th_percentile": 0.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.32, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.32, "10th_percentile": 0.32, "90th_percentile": 0.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.38, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.38, "10th_percentile": 0.38, "90th_percentile": 0.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1.0, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "AMPICILLIN SODIUM 1 G INJ SOLR", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-27280", "type": "CDM" }, { "code": "J0290", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "00781-9404-85", "type": "NDC" } ], "standard_charges": [ { "minimum": 6.04, "maximum": 37.75, "setting": "outpatient", "gross_charge": 37.75, "discounted_cash": 26.42, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 37.75, "10th_percentile": 37.75, "90th_percentile": 37.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 37.75, "10th_percentile": 37.75, "90th_percentile": 37.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 37.75, "10th_percentile": 37.75, "90th_percentile": 37.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 37.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $37.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 37.75, "10th_percentile": 37.75, "90th_percentile": 37.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $37.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 28.31, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 28.31, "10th_percentile": 28.31, "90th_percentile": 28.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 8.12, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 8.12, "10th_percentile": 8.12, "90th_percentile": 8.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 32.09, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 32.09, "10th_percentile": 32.09, "90th_percentile": 32.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 18.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18.88, "10th_percentile": 18.88, "90th_percentile": 18.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 30.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 30.2, "10th_percentile": 30.2, "90th_percentile": 30.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 18.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 18.88, "10th_percentile": 18.88, "90th_percentile": 18.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 28.31, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 28.31, "10th_percentile": 28.31, "90th_percentile": 28.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 26.43, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 26.43, "10th_percentile": 26.43, "90th_percentile": 26.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 12.8, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 12.8, "10th_percentile": 12.8, "90th_percentile": 12.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 22.65, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 22.65, "10th_percentile": 22.65, "90th_percentile": 22.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 30.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 30.2, "10th_percentile": 30.2, "90th_percentile": 30.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 37.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 37.75, "10th_percentile": 37.75, "90th_percentile": 37.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 7.25, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.25, "10th_percentile": 7.25, "90th_percentile": 7.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 7.25, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.25, "10th_percentile": 7.25, "90th_percentile": 7.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 14.77, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.77, "10th_percentile": 14.77, "90th_percentile": 14.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 14.77, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.77, "10th_percentile": 14.77, "90th_percentile": 14.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 6.04, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.04, "10th_percentile": 6.04, "90th_percentile": 6.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 6.04, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.04, "10th_percentile": 6.04, "90th_percentile": 6.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 6.04, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.04, "10th_percentile": 6.04, "90th_percentile": 6.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 37.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 37.75, "10th_percentile": 37.75, "90th_percentile": 37.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 37.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 37.75, "10th_percentile": 37.75, "90th_percentile": 37.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 37.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 37.75, "10th_percentile": 37.75, "90th_percentile": 37.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 37.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 37.75, "10th_percentile": 37.75, "90th_percentile": 37.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 37.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 37.75, "10th_percentile": 37.75, "90th_percentile": 37.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 37.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 37.75, "10th_percentile": 37.75, "90th_percentile": 37.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 37.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 37.75, "10th_percentile": 37.75, "90th_percentile": 37.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 37.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 37.75, "10th_percentile": 37.75, "90th_percentile": 37.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "AMPICILLIN SODIUM 2 G INJ SOLR", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-86990", "type": "CDM" }, { "code": "J0290", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "67850-0022-10", "type": "NDC" } ], "standard_charges": [ { "minimum": 3.52, "maximum": 22.0, "setting": "outpatient", "gross_charge": 22.0, "discounted_cash": 15.4, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 22.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 22.0, "10th_percentile": 22.0, "90th_percentile": 22.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 22.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 22.0, "10th_percentile": 22.0, "90th_percentile": 22.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 22.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 22.0, "10th_percentile": 22.0, "90th_percentile": 22.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 22.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 22.0, "10th_percentile": 22.0, "90th_percentile": 22.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 22.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 22.0, "10th_percentile": 22.0, "90th_percentile": 22.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 22.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 22.0, "10th_percentile": 22.0, "90th_percentile": 22.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 22.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 22.0, "10th_percentile": 22.0, "90th_percentile": 22.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 22.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 22.0, "10th_percentile": 22.0, "90th_percentile": 22.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 22.0, "10th_percentile": 22.0, "90th_percentile": 22.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 22.0, "10th_percentile": 22.0, "90th_percentile": 22.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 22.0, "10th_percentile": 22.0, "90th_percentile": 22.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3.52, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.52, "10th_percentile": 3.52, "90th_percentile": 3.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 3.52, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.52, "10th_percentile": 3.52, "90th_percentile": 3.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3.52, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.52, "10th_percentile": 3.52, "90th_percentile": 3.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 22.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $22.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 22.0, "10th_percentile": 22.0, "90th_percentile": 22.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $22.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 22.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 22.0, "10th_percentile": 22.0, "90th_percentile": 22.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 16.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 16.5, "10th_percentile": 16.5, "90th_percentile": 16.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 11.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.0, "10th_percentile": 11.0, "90th_percentile": 11.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 11.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 11.0, "10th_percentile": 11.0, "90th_percentile": 11.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 15.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 15.4, "10th_percentile": 15.4, "90th_percentile": 15.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 13.2, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 13.2, "10th_percentile": 13.2, "90th_percentile": 13.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 4.73, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 4.73, "10th_percentile": 4.73, "90th_percentile": 4.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 18.7, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 18.7, "10th_percentile": 18.7, "90th_percentile": 18.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 17.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 17.6, "10th_percentile": 17.6, "90th_percentile": 17.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 7.46, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 7.46, "10th_percentile": 7.46, "90th_percentile": 7.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 17.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17.6, "10th_percentile": 17.6, "90th_percentile": 17.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 16.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 16.5, "10th_percentile": 16.5, "90th_percentile": 16.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 4.22, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.22, "10th_percentile": 4.22, "90th_percentile": 4.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 4.22, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.22, "10th_percentile": 4.22, "90th_percentile": 4.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 8.61, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.61, "10th_percentile": 8.61, "90th_percentile": 8.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 8.61, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.61, "10th_percentile": 8.61, "90th_percentile": 8.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "AMPICILLIN SODIUM 500 MG INJ SOLR", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-474", "type": "CDM" }, { "code": "J0290", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "00781-3407-95", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.8, "maximum": 5.0, "setting": "outpatient", "gross_charge": 5.0, "discounted_cash": 3.5, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5.0, "10th_percentile": 5.0, "90th_percentile": 5.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 5.0, "10th_percentile": 5.0, "90th_percentile": 5.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 5.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $5.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 5.0, "10th_percentile": 5.0, "90th_percentile": 5.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $5.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 4.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.0, "10th_percentile": 4.0, "90th_percentile": 4.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 3.0, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 3.0, "10th_percentile": 3.0, "90th_percentile": 3.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 3.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 3.75, "10th_percentile": 3.75, "90th_percentile": 3.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 3.5, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 3.5, "10th_percentile": 3.5, "90th_percentile": 3.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 2.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 4.25, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 4.25, "10th_percentile": 4.25, "90th_percentile": 4.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 3.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 3.75, "10th_percentile": 3.75, "90th_percentile": 3.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 2.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.5, "10th_percentile": 2.5, "90th_percentile": 2.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 5.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 5.0, "10th_percentile": 5.0, "90th_percentile": 5.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 4.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 4.0, "10th_percentile": 4.0, "90th_percentile": 4.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.96, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.96, "10th_percentile": 0.96, "90th_percentile": 0.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.96, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.96, "10th_percentile": 0.96, "90th_percentile": 0.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1.96, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.96, "10th_percentile": 1.96, "90th_percentile": 1.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.8, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.8, "10th_percentile": 0.8, "90th_percentile": 0.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.8, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.8, "10th_percentile": 0.8, "90th_percentile": 0.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.8, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.8, "10th_percentile": 0.8, "90th_percentile": 0.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5.0, "10th_percentile": 5.0, "90th_percentile": 5.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5.0, "10th_percentile": 5.0, "90th_percentile": 5.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5.0, "10th_percentile": 5.0, "90th_percentile": 5.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5.0, "10th_percentile": 5.0, "90th_percentile": 5.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5.0, "10th_percentile": 5.0, "90th_percentile": 5.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5.0, "10th_percentile": 5.0, "90th_percentile": 5.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5.0, "10th_percentile": 5.0, "90th_percentile": 5.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5.0, "10th_percentile": 5.0, "90th_percentile": 5.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5.0, "10th_percentile": 5.0, "90th_percentile": 5.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 1.08, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 1.08, "10th_percentile": 1.08, "90th_percentile": 1.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 1.7, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 1.7, "10th_percentile": 1.7, "90th_percentile": 1.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1.96, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.96, "10th_percentile": 1.96, "90th_percentile": 1.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "AMPICILLIN-SULBACTAM 3 G INJ SOLR", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-27283", "type": "CDM" }, { "code": "J0295", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "00641-6117-10", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.76, "maximum": 17.25, "setting": "outpatient", "gross_charge": 17.25, "discounted_cash": 12.07, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 17.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 17.25, "10th_percentile": 17.25, "90th_percentile": 17.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 17.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 17.25, "10th_percentile": 17.25, "90th_percentile": 17.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 17.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 17.25, "10th_percentile": 17.25, "90th_percentile": 17.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 17.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 17.25, "10th_percentile": 17.25, "90th_percentile": 17.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 17.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 17.25, "10th_percentile": 17.25, "90th_percentile": 17.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 17.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 17.25, "10th_percentile": 17.25, "90th_percentile": 17.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 17.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 17.25, "10th_percentile": 17.25, "90th_percentile": 17.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 17.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 17.25, "10th_percentile": 17.25, "90th_percentile": 17.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 17.25, "10th_percentile": 17.25, "90th_percentile": 17.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 17.25, "10th_percentile": 17.25, "90th_percentile": 17.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 17.25, "10th_percentile": 17.25, "90th_percentile": 17.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2.76, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.76, "10th_percentile": 2.76, "90th_percentile": 2.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 2.76, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.76, "10th_percentile": 2.76, "90th_percentile": 2.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2.76, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.76, "10th_percentile": 2.76, "90th_percentile": 2.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 17.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $17.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 17.25, "10th_percentile": 17.25, "90th_percentile": 17.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $17.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 17.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 17.25, "10th_percentile": 17.25, "90th_percentile": 17.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 12.94, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 12.94, "10th_percentile": 12.94, "90th_percentile": 12.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 8.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.63, "10th_percentile": 8.63, "90th_percentile": 8.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 8.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 8.63, "10th_percentile": 8.63, "90th_percentile": 8.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 12.08, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 12.08, "10th_percentile": 12.08, "90th_percentile": 12.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 10.35, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 10.35, "10th_percentile": 10.35, "90th_percentile": 10.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 3.71, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 3.71, "10th_percentile": 3.71, "90th_percentile": 3.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 14.66, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 14.66, "10th_percentile": 14.66, "90th_percentile": 14.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 13.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 13.8, "10th_percentile": 13.8, "90th_percentile": 13.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 5.85, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 5.85, "10th_percentile": 5.85, "90th_percentile": 5.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 13.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.8, "10th_percentile": 13.8, "90th_percentile": 13.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 12.94, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 12.94, "10th_percentile": 12.94, "90th_percentile": 12.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 3.31, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.31, "10th_percentile": 3.31, "90th_percentile": 3.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 3.31, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.31, "10th_percentile": 3.31, "90th_percentile": 3.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 6.75, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.75, "10th_percentile": 6.75, "90th_percentile": 6.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 6.75, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.75, "10th_percentile": 6.75, "90th_percentile": 6.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "AMPLATZ GUIDEWIRE ULTRA STIFF PTFE FXD CORE 35 INX145CM G53566", "code_information": [ { "code": "SUP-359274", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 11.47, "maximum": 71.66, "setting": "outpatient", "gross_charge": 71.66, "discounted_cash": 50.16, "payers_information": [ { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 21.21, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.95, "10th_percentile": 13.95, "90th_percentile": 13.95, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 36.62, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28.44, "10th_percentile": 28.44, "90th_percentile": 28.44, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 71.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 71.66, "10th_percentile": 71.66, "90th_percentile": 71.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 71.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 71.66, "10th_percentile": 71.66, "90th_percentile": 71.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 71.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 71.66, "10th_percentile": 71.66, "90th_percentile": 71.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 71.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 71.66, "10th_percentile": 71.66, "90th_percentile": 71.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 71.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 71.66, "10th_percentile": 71.66, "90th_percentile": 71.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 71.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 71.66, "10th_percentile": 71.66, "90th_percentile": 71.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 71.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 71.66, "10th_percentile": 71.66, "90th_percentile": 71.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 71.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 71.66, "10th_percentile": 71.66, "90th_percentile": 71.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 71.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $71.66 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 71.66, "10th_percentile": 71.66, "90th_percentile": 71.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $71.66 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 15.41, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 15.41, "10th_percentile": 15.41, "90th_percentile": 15.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 24.29, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 24.29, "10th_percentile": 24.29, "90th_percentile": 24.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 57.33, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 57.33, "10th_percentile": 57.33, "90th_percentile": 57.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 53.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 53.75, "10th_percentile": 53.75, "90th_percentile": 53.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 13.4, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.4, "10th_percentile": 13.4, "90th_percentile": 13.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 35.83, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 35.83, "10th_percentile": 35.83, "90th_percentile": 35.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 53.75, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 53.75, "10th_percentile": 53.75, "90th_percentile": 53.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 57.33, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 57.33, "10th_percentile": 57.33, "90th_percentile": 57.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 43.0, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 43.0, "10th_percentile": 43.0, "90th_percentile": 43.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 32.46, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 32.46, "10th_percentile": 32.46, "90th_percentile": 32.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 46.03, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 46.03, "10th_percentile": 46.03, "90th_percentile": 46.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 60.91, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 60.91, "10th_percentile": 60.91, "90th_percentile": 60.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 71.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 71.66, "10th_percentile": 71.66, "90th_percentile": 71.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 35.83, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 35.83, "10th_percentile": 35.83, "90th_percentile": 35.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 50.16, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 50.16, "10th_percentile": 50.16, "90th_percentile": 50.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 28.04, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28.04, "10th_percentile": 28.04, "90th_percentile": 28.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 28.04, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 28.04, "10th_percentile": 28.04, "90th_percentile": 28.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 40.7, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 40.7, "10th_percentile": 40.7, "90th_percentile": 40.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 40.7, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 40.7, "10th_percentile": 40.7, "90th_percentile": 40.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 13.76, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.76, "10th_percentile": 13.76, "90th_percentile": 13.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 13.76, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.76, "10th_percentile": 13.76, "90th_percentile": 13.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 11.47, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.47, "10th_percentile": 11.47, "90th_percentile": 11.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 11.47, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.47, "10th_percentile": 11.47, "90th_percentile": 11.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 11.47, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.47, "10th_percentile": 11.47, "90th_percentile": 11.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 71.66, "10th_percentile": 71.66, "90th_percentile": 71.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 71.66, "10th_percentile": 71.66, "90th_percentile": 71.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 71.66, "10th_percentile": 71.66, "90th_percentile": 71.66, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "ANCHOR 1.8MM 2 TAPE VERSALOOP", "code_information": [ { "code": "SUP-419059", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 228.74, "maximum": 1429.65, "setting": "outpatient", "gross_charge": 1429.65, "discounted_cash": 1000.75, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 730.55, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 252.68, "10th_percentile": 252.68, "90th_percentile": 252.68, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 307.37, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 373.87, "10th_percentile": 373.87, "90th_percentile": 373.87, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 228.74, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 228.74, "10th_percentile": 228.74, "90th_percentile": 228.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 228.74, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 228.74, "10th_percentile": 228.74, "90th_percentile": 228.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 228.74, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 228.74, "10th_percentile": 228.74, "90th_percentile": 228.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 274.49, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 274.49, "10th_percentile": 274.49, "90th_percentile": 274.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 274.49, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 274.49, "10th_percentile": 274.49, "90th_percentile": 274.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 812.04, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 812.04, "10th_percentile": 812.04, "90th_percentile": 812.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 812.04, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 812.04, "10th_percentile": 812.04, "90th_percentile": 812.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 559.42, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 559.42, "10th_percentile": 559.42, "90th_percentile": 559.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 559.42, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 559.42, "10th_percentile": 559.42, "90th_percentile": 559.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 423.18, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.51, "10th_percentile": 5.51, "90th_percentile": 5.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1072.24, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1072.24, "10th_percentile": 1072.24, "90th_percentile": 1072.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1143.72, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1143.72, "10th_percentile": 1143.72, "90th_percentile": 1143.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 918.26, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 918.26, "10th_percentile": 918.26, "90th_percentile": 918.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1429.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,429.65 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1429.65, "10th_percentile": 1429.65, "90th_percentile": 1429.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,429.65 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 714.83, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 714.83, "10th_percentile": 714.83, "90th_percentile": 714.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1143.72, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1143.72, "10th_percentile": 1143.72, "90th_percentile": 1143.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 647.63, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 647.63, "10th_percentile": 647.63, "90th_percentile": 647.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 714.83, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 714.83, "10th_percentile": 714.83, "90th_percentile": 714.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1215.2, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1215.2, "10th_percentile": 1215.2, "90th_percentile": 1215.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1000.76, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1000.76, "10th_percentile": 1000.76, "90th_percentile": 1000.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 484.65, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 484.65, "10th_percentile": 484.65, "90th_percentile": 484.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1429.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1429.65, "10th_percentile": 1429.65, "90th_percentile": 1429.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 857.79, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 857.79, "10th_percentile": 857.79, "90th_percentile": 857.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1072.24, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1072.24, "10th_percentile": 1072.24, "90th_percentile": 1072.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 267.34, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 267.34, "10th_percentile": 267.34, "90th_percentile": 267.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1429.65, "10th_percentile": 1429.65, "90th_percentile": 1429.65, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1429.65, "10th_percentile": 1429.65, "90th_percentile": 1429.65, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1429.65, "10th_percentile": 1429.65, "90th_percentile": 1429.65, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1429.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1429.65, "10th_percentile": 1429.65, "90th_percentile": 1429.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1429.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1429.65, "10th_percentile": 1429.65, "90th_percentile": 1429.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1429.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1429.65, "10th_percentile": 1429.65, "90th_percentile": 1429.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1429.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1429.65, "10th_percentile": 1429.65, "90th_percentile": 1429.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1429.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1429.65, "10th_percentile": 1429.65, "90th_percentile": 1429.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1429.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1429.65, "10th_percentile": 1429.65, "90th_percentile": 1429.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1429.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1429.65, "10th_percentile": 1429.65, "90th_percentile": 1429.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1429.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1429.65, "10th_percentile": 1429.65, "90th_percentile": 1429.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "ANCHOR KIT TIGHTROPE AR-1588TN-1", "code_information": [ { "code": "SUP-149362", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 74.34, "maximum": 464.63, "setting": "outpatient", "gross_charge": 464.63, "discounted_cash": 325.24, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 237.43, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 252.68, "10th_percentile": 252.68, "90th_percentile": 252.68, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 99.9, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 373.87, "10th_percentile": 373.87, "90th_percentile": 373.87, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 74.34, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 74.34, "10th_percentile": 74.34, "90th_percentile": 74.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 74.34, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 74.34, "10th_percentile": 74.34, "90th_percentile": 74.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 74.34, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 74.34, "10th_percentile": 74.34, "90th_percentile": 74.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 89.21, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 89.21, "10th_percentile": 89.21, "90th_percentile": 89.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 89.21, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 89.21, "10th_percentile": 89.21, "90th_percentile": 89.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 263.91, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 263.91, "10th_percentile": 263.91, "90th_percentile": 263.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 263.91, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 263.91, "10th_percentile": 263.91, "90th_percentile": 263.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 181.81, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 181.81, "10th_percentile": 181.81, "90th_percentile": 181.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 181.81, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 181.81, "10th_percentile": 181.81, "90th_percentile": 181.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 137.53, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.51, "10th_percentile": 5.51, "90th_percentile": 5.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 348.47, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 348.47, "10th_percentile": 348.47, "90th_percentile": 348.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 371.7, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 371.7, "10th_percentile": 371.7, "90th_percentile": 371.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 298.43, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 298.43, "10th_percentile": 298.43, "90th_percentile": 298.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 464.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $464.63 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 464.63, "10th_percentile": 464.63, "90th_percentile": 464.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $464.63 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 232.32, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 232.32, "10th_percentile": 232.32, "90th_percentile": 232.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 371.7, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 371.7, "10th_percentile": 371.7, "90th_percentile": 371.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 210.48, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 210.48, "10th_percentile": 210.48, "90th_percentile": 210.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 232.32, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 232.32, "10th_percentile": 232.32, "90th_percentile": 232.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 394.94, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 394.94, "10th_percentile": 394.94, "90th_percentile": 394.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 325.24, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 325.24, "10th_percentile": 325.24, "90th_percentile": 325.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 157.51, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 157.51, "10th_percentile": 157.51, "90th_percentile": 157.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 464.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 464.63, "10th_percentile": 464.63, "90th_percentile": 464.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 278.78, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 278.78, "10th_percentile": 278.78, "90th_percentile": 278.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 348.47, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 348.47, "10th_percentile": 348.47, "90th_percentile": 348.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 86.89, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 86.89, "10th_percentile": 86.89, "90th_percentile": 86.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 464.63, "10th_percentile": 464.63, "90th_percentile": 464.63, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 464.63, "10th_percentile": 464.63, "90th_percentile": 464.63, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 464.63, "10th_percentile": 464.63, "90th_percentile": 464.63, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 464.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 464.63, "10th_percentile": 464.63, "90th_percentile": 464.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 464.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 464.63, "10th_percentile": 464.63, "90th_percentile": 464.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 464.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 464.63, "10th_percentile": 464.63, "90th_percentile": 464.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 464.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 464.63, "10th_percentile": 464.63, "90th_percentile": 464.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 464.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 464.63, "10th_percentile": 464.63, "90th_percentile": 464.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 464.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 464.63, "10th_percentile": 464.63, "90th_percentile": 464.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 464.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 464.63, "10th_percentile": 464.63, "90th_percentile": 464.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 464.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 464.63, "10th_percentile": 464.63, "90th_percentile": 464.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "ANCHOR QUICK ANCHOR+ 212859", "code_information": [ { "code": "SUP-143056", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 195.95, "maximum": 1224.68, "setting": "outpatient", "gross_charge": 1224.68, "discounted_cash": 857.28, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 625.81, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 252.68, "10th_percentile": 252.68, "90th_percentile": 252.68, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 263.31, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 373.87, "10th_percentile": 373.87, "90th_percentile": 373.87, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 195.95, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 195.95, "10th_percentile": 195.95, "90th_percentile": 195.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 195.95, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 195.95, "10th_percentile": 195.95, "90th_percentile": 195.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 195.95, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 195.95, "10th_percentile": 195.95, "90th_percentile": 195.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 235.14, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 235.14, "10th_percentile": 235.14, "90th_percentile": 235.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 235.14, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 235.14, "10th_percentile": 235.14, "90th_percentile": 235.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 695.62, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 695.62, "10th_percentile": 695.62, "90th_percentile": 695.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 695.62, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 695.62, "10th_percentile": 695.62, "90th_percentile": 695.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 479.22, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 479.22, "10th_percentile": 479.22, "90th_percentile": 479.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 479.22, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 479.22, "10th_percentile": 479.22, "90th_percentile": 479.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 362.51, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.51, "10th_percentile": 5.51, "90th_percentile": 5.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 918.51, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 918.51, "10th_percentile": 918.51, "90th_percentile": 918.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 979.74, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 979.74, "10th_percentile": 979.74, "90th_percentile": 979.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 786.61, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 786.61, "10th_percentile": 786.61, "90th_percentile": 786.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1224.68, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,224.68 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1224.68, "10th_percentile": 1224.68, "90th_percentile": 1224.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,224.68 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 612.34, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 612.34, "10th_percentile": 612.34, "90th_percentile": 612.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 979.74, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 979.74, "10th_percentile": 979.74, "90th_percentile": 979.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 554.78, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 554.78, "10th_percentile": 554.78, "90th_percentile": 554.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 612.34, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 612.34, "10th_percentile": 612.34, "90th_percentile": 612.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1040.98, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1040.98, "10th_percentile": 1040.98, "90th_percentile": 1040.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 857.28, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 857.28, "10th_percentile": 857.28, "90th_percentile": 857.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 415.17, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 415.17, "10th_percentile": 415.17, "90th_percentile": 415.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1224.68, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1224.68, "10th_percentile": 1224.68, "90th_percentile": 1224.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 734.81, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 734.81, "10th_percentile": 734.81, "90th_percentile": 734.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 918.51, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 918.51, "10th_percentile": 918.51, "90th_percentile": 918.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 229.02, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 229.02, "10th_percentile": 229.02, "90th_percentile": 229.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1224.68, "10th_percentile": 1224.68, "90th_percentile": 1224.68, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1224.68, "10th_percentile": 1224.68, "90th_percentile": 1224.68, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1224.68, "10th_percentile": 1224.68, "90th_percentile": 1224.68, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1224.68, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1224.68, "10th_percentile": 1224.68, "90th_percentile": 1224.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1224.68, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1224.68, "10th_percentile": 1224.68, "90th_percentile": 1224.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1224.68, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1224.68, "10th_percentile": 1224.68, "90th_percentile": 1224.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1224.68, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1224.68, "10th_percentile": 1224.68, "90th_percentile": 1224.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1224.68, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1224.68, "10th_percentile": 1224.68, "90th_percentile": 1224.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1224.68, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1224.68, "10th_percentile": 1224.68, "90th_percentile": 1224.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1224.68, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1224.68, "10th_percentile": 1224.68, "90th_percentile": 1224.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1224.68, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1224.68, "10th_percentile": 1224.68, "90th_percentile": 1224.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "ANCHOR SUTURE 3.4MM DBL ARMED PEEK HEALIX TRANSTEND", "code_information": [ { "code": "SUP-374682", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 253.34, "maximum": 1583.38, "setting": "outpatient", "gross_charge": 1583.38, "discounted_cash": 1108.37, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 809.11, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 252.68, "10th_percentile": 252.68, "90th_percentile": 252.68, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 340.43, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 373.87, "10th_percentile": 373.87, "90th_percentile": 373.87, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 253.34, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 253.34, "10th_percentile": 253.34, "90th_percentile": 253.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 253.34, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 253.34, "10th_percentile": 253.34, "90th_percentile": 253.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 253.34, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 253.34, "10th_percentile": 253.34, "90th_percentile": 253.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 304.01, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 304.01, "10th_percentile": 304.01, "90th_percentile": 304.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 304.01, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 304.01, "10th_percentile": 304.01, "90th_percentile": 304.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 899.36, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 899.36, "10th_percentile": 899.36, "90th_percentile": 899.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 899.36, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 899.36, "10th_percentile": 899.36, "90th_percentile": 899.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 619.58, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 619.58, "10th_percentile": 619.58, "90th_percentile": 619.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 619.58, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 619.58, "10th_percentile": 619.58, "90th_percentile": 619.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 468.68, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.51, "10th_percentile": 5.51, "90th_percentile": 5.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1266.7, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1266.7, "10th_percentile": 1266.7, "90th_percentile": 1266.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1108.37, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1108.37, "10th_percentile": 1108.37, "90th_percentile": 1108.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 296.09, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 296.09, "10th_percentile": 296.09, "90th_percentile": 296.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 791.69, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 791.69, "10th_percentile": 791.69, "90th_percentile": 791.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1583.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1583.38, "10th_percentile": 1583.38, "90th_percentile": 1583.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1583.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,583.38 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1583.38, "10th_percentile": 1583.38, "90th_percentile": 1583.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,583.38 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1187.54, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1187.54, "10th_percentile": 1187.54, "90th_percentile": 1187.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 950.03, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 950.03, "10th_percentile": 950.03, "90th_percentile": 950.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1187.54, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1187.54, "10th_percentile": 1187.54, "90th_percentile": 1187.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 536.77, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 536.77, "10th_percentile": 536.77, "90th_percentile": 536.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1017.0, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1017.0, "10th_percentile": 1017.0, "90th_percentile": 1017.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 717.27, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 717.27, "10th_percentile": 717.27, "90th_percentile": 717.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1266.7, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1266.7, "10th_percentile": 1266.7, "90th_percentile": 1266.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 791.69, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 791.69, "10th_percentile": 791.69, "90th_percentile": 791.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1345.87, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1345.87, "10th_percentile": 1345.87, "90th_percentile": 1345.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1583.38, "10th_percentile": 1583.38, "90th_percentile": 1583.38, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1583.38, "10th_percentile": 1583.38, "90th_percentile": 1583.38, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1583.38, "10th_percentile": 1583.38, "90th_percentile": 1583.38, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1583.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1583.38, "10th_percentile": 1583.38, "90th_percentile": 1583.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1583.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1583.38, "10th_percentile": 1583.38, "90th_percentile": 1583.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1583.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1583.38, "10th_percentile": 1583.38, "90th_percentile": 1583.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1583.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1583.38, "10th_percentile": 1583.38, "90th_percentile": 1583.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1583.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1583.38, "10th_percentile": 1583.38, "90th_percentile": 1583.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1583.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1583.38, "10th_percentile": 1583.38, "90th_percentile": 1583.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1583.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1583.38, "10th_percentile": 1583.38, "90th_percentile": 1583.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1583.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1583.38, "10th_percentile": 1583.38, "90th_percentile": 1583.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "ANCHOR SUTURE 5.5", "code_information": [ { "code": "SUP-378618", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 122.98, "maximum": 768.63, "setting": "outpatient", "gross_charge": 768.63, "discounted_cash": 538.04, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 392.77, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 252.68, "10th_percentile": 252.68, "90th_percentile": 252.68, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 165.26, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 373.87, "10th_percentile": 373.87, "90th_percentile": 373.87, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 122.98, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 122.98, "10th_percentile": 122.98, "90th_percentile": 122.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 122.98, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 122.98, "10th_percentile": 122.98, "90th_percentile": 122.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 122.98, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 122.98, "10th_percentile": 122.98, "90th_percentile": 122.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 147.58, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 147.58, "10th_percentile": 147.58, "90th_percentile": 147.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 147.58, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 147.58, "10th_percentile": 147.58, "90th_percentile": 147.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 436.58, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 436.58, "10th_percentile": 436.58, "90th_percentile": 436.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 436.58, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 436.58, "10th_percentile": 436.58, "90th_percentile": 436.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 300.76, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 300.76, "10th_percentile": 300.76, "90th_percentile": 300.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 300.76, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 300.76, "10th_percentile": 300.76, "90th_percentile": 300.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 227.51, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.51, "10th_percentile": 5.51, "90th_percentile": 5.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 614.9, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 614.9, "10th_percentile": 614.9, "90th_percentile": 614.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 538.04, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 538.04, "10th_percentile": 538.04, "90th_percentile": 538.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 143.73, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 143.73, "10th_percentile": 143.73, "90th_percentile": 143.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 384.32, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 384.32, "10th_percentile": 384.32, "90th_percentile": 384.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 768.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 768.63, "10th_percentile": 768.63, "90th_percentile": 768.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 768.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $768.63 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 768.63, "10th_percentile": 768.63, "90th_percentile": 768.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $768.63 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 576.47, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 576.47, "10th_percentile": 576.47, "90th_percentile": 576.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 461.18, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 461.18, "10th_percentile": 461.18, "90th_percentile": 461.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 576.47, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 576.47, "10th_percentile": 576.47, "90th_percentile": 576.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 260.57, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 260.57, "10th_percentile": 260.57, "90th_percentile": 260.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 493.69, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 493.69, "10th_percentile": 493.69, "90th_percentile": 493.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 348.19, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 348.19, "10th_percentile": 348.19, "90th_percentile": 348.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 614.9, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 614.9, "10th_percentile": 614.9, "90th_percentile": 614.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 384.32, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 384.32, "10th_percentile": 384.32, "90th_percentile": 384.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 653.34, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 653.34, "10th_percentile": 653.34, "90th_percentile": 653.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 768.63, "10th_percentile": 768.63, "90th_percentile": 768.63, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 768.63, "10th_percentile": 768.63, "90th_percentile": 768.63, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 768.63, "10th_percentile": 768.63, "90th_percentile": 768.63, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 768.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 768.63, "10th_percentile": 768.63, "90th_percentile": 768.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 768.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 768.63, "10th_percentile": 768.63, "90th_percentile": 768.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 768.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 768.63, "10th_percentile": 768.63, "90th_percentile": 768.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 768.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 768.63, "10th_percentile": 768.63, "90th_percentile": 768.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 768.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 768.63, "10th_percentile": 768.63, "90th_percentile": 768.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 768.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 768.63, "10th_percentile": 768.63, "90th_percentile": 768.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 768.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 768.63, "10th_percentile": 768.63, "90th_percentile": 768.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 768.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 768.63, "10th_percentile": 768.63, "90th_percentile": 768.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "ANCHOR SUTURE 5MM ORTHOCORD FASTIN RC NEEDLE STERILE", "code_information": [ { "code": "SUP-416212", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 161.92, "maximum": 1012.03, "setting": "outpatient", "gross_charge": 1012.03, "discounted_cash": 708.42, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 217.59, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 373.87, "10th_percentile": 373.87, "90th_percentile": 373.87, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 161.92, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 161.92, "10th_percentile": 161.92, "90th_percentile": 161.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 574.83, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 574.83, "10th_percentile": 574.83, "90th_percentile": 574.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 194.31, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 194.31, "10th_percentile": 194.31, "90th_percentile": 194.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 396.01, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 396.01, "10th_percentile": 396.01, "90th_percentile": 396.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 809.62, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 809.62, "10th_percentile": 809.62, "90th_percentile": 809.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 343.08, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 343.08, "10th_percentile": 343.08, "90th_percentile": 343.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1012.03, "10th_percentile": 1012.03, "90th_percentile": 1012.03, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1012.03, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1012.03, "10th_percentile": 1012.03, "90th_percentile": 1012.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 517.15, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 252.68, "10th_percentile": 252.68, "90th_percentile": 252.68, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 161.92, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 161.92, "10th_percentile": 161.92, "90th_percentile": 161.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 161.92, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 161.92, "10th_percentile": 161.92, "90th_percentile": 161.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 194.31, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 194.31, "10th_percentile": 194.31, "90th_percentile": 194.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 574.83, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 574.83, "10th_percentile": 574.83, "90th_percentile": 574.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 396.01, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 396.01, "10th_percentile": 396.01, "90th_percentile": 396.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 299.56, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.51, "10th_percentile": 5.51, "90th_percentile": 5.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 708.42, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 708.42, "10th_percentile": 708.42, "90th_percentile": 708.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 189.25, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 189.25, "10th_percentile": 189.25, "90th_percentile": 189.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 506.02, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 506.02, "10th_percentile": 506.02, "90th_percentile": 506.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1012.03, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1012.03, "10th_percentile": 1012.03, "90th_percentile": 1012.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1012.03, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,012.03 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1012.03, "10th_percentile": 1012.03, "90th_percentile": 1012.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,012.03 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 759.02, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 759.02, "10th_percentile": 759.02, "90th_percentile": 759.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 607.22, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 607.22, "10th_percentile": 607.22, "90th_percentile": 607.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 759.02, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 759.02, "10th_percentile": 759.02, "90th_percentile": 759.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 650.03, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 650.03, "10th_percentile": 650.03, "90th_percentile": 650.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 458.45, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 458.45, "10th_percentile": 458.45, "90th_percentile": 458.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 809.62, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 809.62, "10th_percentile": 809.62, "90th_percentile": 809.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 506.02, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 506.02, "10th_percentile": 506.02, "90th_percentile": 506.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 860.23, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 860.23, "10th_percentile": 860.23, "90th_percentile": 860.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1012.03, "10th_percentile": 1012.03, "90th_percentile": 1012.03, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1012.03, "10th_percentile": 1012.03, "90th_percentile": 1012.03, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1012.03, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1012.03, "10th_percentile": 1012.03, "90th_percentile": 1012.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1012.03, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1012.03, "10th_percentile": 1012.03, "90th_percentile": 1012.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1012.03, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1012.03, "10th_percentile": 1012.03, "90th_percentile": 1012.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1012.03, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1012.03, "10th_percentile": 1012.03, "90th_percentile": 1012.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1012.03, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1012.03, "10th_percentile": 1012.03, "90th_percentile": 1012.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1012.03, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1012.03, "10th_percentile": 1012.03, "90th_percentile": 1012.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1012.03, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1012.03, "10th_percentile": 1012.03, "90th_percentile": 1012.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "ANGIOPLASTY PACK LARGE BORE", "code_information": [ { "code": "SUP-11249", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 4.29, "maximum": 30.66, "setting": "outpatient", "gross_charge": 30.66, "discounted_cash": 21.46, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 12.0, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 5.19, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.19, "10th_percentile": 5.19, "90th_percentile": 5.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 4.38, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.38, "10th_percentile": 4.38, "90th_percentile": 4.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 4.29, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.29, "10th_percentile": 4.29, "90th_percentile": 4.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 13.58, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.58, "10th_percentile": 13.58, "90th_percentile": 13.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 30.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $30.66 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 30.66, "10th_percentile": 30.66, "90th_percentile": 30.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $30.66 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 10.39, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 10.39, "10th_percentile": 10.39, "90th_percentile": 10.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 6.59, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 6.59, "10th_percentile": 6.59, "90th_percentile": 6.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 23.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 23.0, "10th_percentile": 23.0, "90th_percentile": 23.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 23.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 23.0, "10th_percentile": 23.0, "90th_percentile": 23.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 12.0, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 26.06, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 26.06, "10th_percentile": 26.06, "90th_percentile": 26.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 21.46, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 21.46, "10th_percentile": 21.46, "90th_percentile": 21.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 15.33, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 15.33, "10th_percentile": 15.33, "90th_percentile": 15.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 15.33, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15.33, "10th_percentile": 15.33, "90th_percentile": 15.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 18.4, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 18.4, "10th_percentile": 18.4, "90th_percentile": 18.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 19.69, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 19.69, "10th_percentile": 19.69, "90th_percentile": 19.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 13.58, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.58, "10th_percentile": 13.58, "90th_percentile": 13.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 24.53, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.53, "10th_percentile": 24.53, "90th_percentile": 24.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 5.73, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.73, "10th_percentile": 5.73, "90th_percentile": 5.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 9.08, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.08, "10th_percentile": 9.08, "90th_percentile": 9.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 24.53, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 24.53, "10th_percentile": 24.53, "90th_percentile": 24.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 30.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 30.66, "10th_percentile": 30.66, "90th_percentile": 30.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 13.89, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.89, "10th_percentile": 13.89, "90th_percentile": 13.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 15.67, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15.67, "10th_percentile": 15.67, "90th_percentile": 15.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 17.41, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17.41, "10th_percentile": 17.41, "90th_percentile": 17.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 17.41, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17.41, "10th_percentile": 17.41, "90th_percentile": 17.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 30.66, "10th_percentile": 30.66, "90th_percentile": 30.66, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 30.66, "10th_percentile": 30.66, "90th_percentile": 30.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 30.66, "10th_percentile": 30.66, "90th_percentile": 30.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 30.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 30.66, "10th_percentile": 30.66, "90th_percentile": 30.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 30.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 30.66, "10th_percentile": 30.66, "90th_percentile": 30.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 30.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 30.66, "10th_percentile": 30.66, "90th_percentile": 30.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 30.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 30.66, "10th_percentile": 30.66, "90th_percentile": 30.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 30.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 30.66, "10th_percentile": 30.66, "90th_percentile": 30.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 30.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 30.66, "10th_percentile": 30.66, "90th_percentile": 30.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 30.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 30.66, "10th_percentile": 30.66, "90th_percentile": 30.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 30.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 30.66, "10th_percentile": 30.66, "90th_percentile": 30.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "APPENDIX PROCEDURES WITHOUT CC/MCC", "code_information": [ { "code": "399", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 8145.49, "maximum": 16672.56, "setting": "inpatient", "gross_charge": 57861.51, "discounted_cash": 40503.06, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_dollar": 8145.49, "standard_charge_algorithm": "Re-evaluated: HLB.797831793; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.14, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $8,648.26; Additional payment reduction: $86.48; Total: $8,561.78", "median_amount": 8561.78, "10th_percentile": 8561.78, "90th_percentile": 8561.78, "count": "13", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.797831793; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.14, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $8,648.26; Additional payment reduction: $86.48; Total: $8,561.78" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_dollar": 8145.49, "standard_charge_algorithm": "Re-evaluated: HLB.797831793; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.14, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $8,648.26; Additional payment reduction: $86.48; Total: $8,561.78", "median_amount": 8561.78, "10th_percentile": 8561.78, "90th_percentile": 8561.78, "count": "13", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.797831793; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 1.14, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $8,648.26; Additional payment reduction: $86.48; Total: $8,561.78" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.797831793; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services; 100% Billed", "median_amount": 57843.52, "10th_percentile": 57843.52, "90th_percentile": 57843.52, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.797831793; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services; 100% Billed", "median_amount": 57843.52, "10th_percentile": 57843.52, "90th_percentile": 57843.52, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.797831793; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services; 100% Billed", "median_amount": 57843.52, "10th_percentile": 57843.52, "90th_percentile": 57843.52, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.797831793; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services; 100% Billed", "median_amount": 57843.52, "10th_percentile": 57843.52, "90th_percentile": 57843.52, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.797831793; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services; 100% Billed", "median_amount": 57843.52, "10th_percentile": 57843.52, "90th_percentile": 57843.52, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.797831793; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services; 100% Billed", "median_amount": 57843.52, "10th_percentile": 57843.52, "90th_percentile": 57843.52, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.797831793; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services; 100% Billed", "median_amount": 57843.52, "10th_percentile": 57843.52, "90th_percentile": 57843.52, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.797831793; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services; 100% Billed", "median_amount": 57843.52, "10th_percentile": 57843.52, "90th_percentile": 57843.52, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.797831793; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services - OON; 100% Billed", "median_amount": 57843.52, "10th_percentile": 57843.52, "90th_percentile": 57843.52, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Re-evaluated: HLB.797831793; Using historical claim(s); Scope: All Financial Classes; Cases: 13; Inpatient; 80% Billed", "median_amount": 46274.82, "10th_percentile": 46274.82, "90th_percentile": 46274.82, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 30.4, "standard_charge_algorithm": "Re-evaluated: HLB.797831793; Using historical claim(s); Scope: All Financial Classes; Cases: 13; IP Services. ADP RATE (for patient estimates only); 30.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17584.43, "10th_percentile": 17584.43, "90th_percentile": 17584.43, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 20066.16, "10th_percentile": 20066.16, "90th_percentile": 20066.16, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_percentage": 21.5, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 12436.42, "10th_percentile": 12436.42, "90th_percentile": 12436.42, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_percentage": 34.2, "standard_charge_algorithm": "Re-evaluated: HLB.797831793; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All Inpatient Services; 34.2% Billed", "median_amount": 19782.48, "10th_percentile": 19782.48, "90th_percentile": 19782.48, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 28921.76, "10th_percentile": 28921.76, "90th_percentile": 28921.76, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Re-evaluated: HLB.797831793; Using historical claim(s); Scope: All Financial Classes; Cases: 13; Inpatient Services; 50% Billed", "median_amount": 28921.76, "10th_percentile": 28921.76, "90th_percentile": 28921.76, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Re-evaluated: HLB.797831793; Using historical claim(s); Scope: All Financial Classes; Cases: 13; STOP LOSS; 75% Billed", "median_amount": 43382.64, "10th_percentile": 43382.64, "90th_percentile": 43382.64, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Re-evaluated: HLB.797831793; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services; 75% Billed", "median_amount": 43382.64, "10th_percentile": 43382.64, "90th_percentile": 43382.64, "count": "13", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 11775.53, "standard_charge_algorithm": "Re-evaluated: HLB.797831793; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1447, Rate: 10,287.00, and; Pricing Extension - NM HB XR PRC - PH BCBS HMO STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11775.53, "10th_percentile": 11775.53, "90th_percentile": 11775.53, "count": "13", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 9804.36, "standard_charge_algorithm": "Re-evaluated: HLB.797831793; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1447, Rate: 8,565.00, and; Pricing Extension - NM HB XR PRC - PH BCBS CHOICE PREF STOP LOSS & LESSOR OF 9.*; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9804.36, "10th_percentile": 9804.36, "90th_percentile": 9804.36, "count": "13", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 16672.56, "standard_charge_algorithm": "Re-evaluated: HLB.797831793; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1447, Rate: 14,565.00, and; Pricing Extension - NM HB XR PRC - PH BCBS PPO STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 82773.68, "10th_percentile": 82773.68, "90th_percentile": 82773.68, "count": "13", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 9163.32, "standard_charge_algorithm": "Re-evaluated: HLB.797831793; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1447, Rate: 8,005.00, and; Pricing Extension - NM HB XR PRC - PH BCBS CHOICE SELECT STOP LOSS & LESSOR OF *; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9163.32, "10th_percentile": 9163.32, "90th_percentile": 9163.32, "count": "13", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 10353.81, "standard_charge_algorithm": "Re-evaluated: HLB.797831793; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1447, Rate: 9,045.00, and; Pricing Extension - NM HB XR PRC - PH BCBS CHOICE STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10353.81, "10th_percentile": 10353.81, "90th_percentile": 10353.81, "count": "13", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 11775.53, "standard_charge_algorithm": "Re-evaluated: HLB.797831793; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1447, Rate: 10,287.00, and; Pricing Extension - NM HB XR PRC - PH BCBS HMO STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11775.53, "10th_percentile": 11775.53, "90th_percentile": 11775.53, "count": "13", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 16672.56, "standard_charge_algorithm": "Re-evaluated: HLB.797831793; Using historical claim(s); Scope: All Financial Classes; Cases: 13; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 1.1447, Rate: 14,565.00, and; Pricing Extension - NM HB XR PRC - PH BCBS PPO STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 82773.68, "10th_percentile": 82773.68, "90th_percentile": 82773.68, "count": "13", "methodology": "case rate" } ] } ] }, { "description": "ARCHON SCR SPNL 4.0X13MM SD FIXED 8780713", "code_information": [ { "code": "SUP-324755", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 30.75, "maximum": 192.16, "setting": "outpatient", "gross_charge": 192.16, "discounted_cash": 134.51, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 98.19, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 252.68, "10th_percentile": 252.68, "90th_percentile": 252.68, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 115.3, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 115.3, "10th_percentile": 115.3, "90th_percentile": 115.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 163.34, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 163.34, "10th_percentile": 163.34, "90th_percentile": 163.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 96.08, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 96.08, "10th_percentile": 96.08, "90th_percentile": 96.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 123.42, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 123.42, "10th_percentile": 123.42, "90th_percentile": 123.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 192.16, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 192.16, "10th_percentile": 192.16, "90th_percentile": 192.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 134.51, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 134.51, "10th_percentile": 134.51, "90th_percentile": 134.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 87.05, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 87.05, "10th_percentile": 87.05, "90th_percentile": 87.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 192.16, "10th_percentile": 192.16, "90th_percentile": 192.16, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 192.16, "10th_percentile": 192.16, "90th_percentile": 192.16, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 192.16, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 192.16, "10th_percentile": 192.16, "90th_percentile": 192.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 192.16, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 192.16, "10th_percentile": 192.16, "90th_percentile": 192.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 192.16, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 192.16, "10th_percentile": 192.16, "90th_percentile": 192.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 192.16, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 192.16, "10th_percentile": 192.16, "90th_percentile": 192.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 192.16, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 192.16, "10th_percentile": 192.16, "90th_percentile": 192.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 41.31, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 373.87, "10th_percentile": 373.87, "90th_percentile": 373.87, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 30.75, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 30.75, "10th_percentile": 30.75, "90th_percentile": 30.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 30.75, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 30.75, "10th_percentile": 30.75, "90th_percentile": 30.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 30.75, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 30.75, "10th_percentile": 30.75, "90th_percentile": 30.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 36.89, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.89, "10th_percentile": 36.89, "90th_percentile": 36.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 36.89, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.89, "10th_percentile": 36.89, "90th_percentile": 36.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 109.15, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 109.15, "10th_percentile": 109.15, "90th_percentile": 109.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 109.15, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 109.15, "10th_percentile": 109.15, "90th_percentile": 109.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 75.19, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 75.19, "10th_percentile": 75.19, "90th_percentile": 75.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 75.19, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 75.19, "10th_percentile": 75.19, "90th_percentile": 75.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 56.88, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.51, "10th_percentile": 5.51, "90th_percentile": 5.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 153.73, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 153.73, "10th_percentile": 153.73, "90th_percentile": 153.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 35.93, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 35.93, "10th_percentile": 35.93, "90th_percentile": 35.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 192.16, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $192.16 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 192.16, "10th_percentile": 192.16, "90th_percentile": 192.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $192.16 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 144.12, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 144.12, "10th_percentile": 144.12, "90th_percentile": 144.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 144.12, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 144.12, "10th_percentile": 144.12, "90th_percentile": 144.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 65.14, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 65.14, "10th_percentile": 65.14, "90th_percentile": 65.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 153.73, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 153.73, "10th_percentile": 153.73, "90th_percentile": 153.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 96.08, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 96.08, "10th_percentile": 96.08, "90th_percentile": 96.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 192.16, "10th_percentile": 192.16, "90th_percentile": 192.16, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 192.16, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 192.16, "10th_percentile": 192.16, "90th_percentile": 192.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 192.16, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 192.16, "10th_percentile": 192.16, "90th_percentile": 192.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 192.16, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 192.16, "10th_percentile": 192.16, "90th_percentile": 192.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "ARGATROBAN 100 MG/ML IV SOLN", "drug_information": { "unit": 2.5, "type": "ML" }, "code_information": [ { "code": "RX-28947", "type": "CDM" }, { "code": "J0883", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "00143-9674-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 136.72, "maximum": 854.5, "setting": "outpatient", "gross_charge": 854.5, "discounted_cash": 598.15, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 854.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 854.5, "10th_percentile": 854.5, "90th_percentile": 854.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 854.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 854.5, "10th_percentile": 854.5, "90th_percentile": 854.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 854.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 854.5, "10th_percentile": 854.5, "90th_percentile": 854.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 854.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 854.5, "10th_percentile": 854.5, "90th_percentile": 854.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 854.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 854.5, "10th_percentile": 854.5, "90th_percentile": 854.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 854.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 854.5, "10th_percentile": 854.5, "90th_percentile": 854.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 854.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 854.5, "10th_percentile": 854.5, "90th_percentile": 854.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 854.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 854.5, "10th_percentile": 854.5, "90th_percentile": 854.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 854.5, "10th_percentile": 854.5, "90th_percentile": 854.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 854.5, "10th_percentile": 854.5, "90th_percentile": 854.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 854.5, "10th_percentile": 854.5, "90th_percentile": 854.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 136.72, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 136.72, "10th_percentile": 136.72, "90th_percentile": 136.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 136.72, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 136.72, "10th_percentile": 136.72, "90th_percentile": 136.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 136.72, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 136.72, "10th_percentile": 136.72, "90th_percentile": 136.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 334.37, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 334.37, "10th_percentile": 334.37, "90th_percentile": 334.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 334.37, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 334.37, "10th_percentile": 334.37, "90th_percentile": 334.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 164.06, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 164.06, "10th_percentile": 164.06, "90th_percentile": 164.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 164.06, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 164.06, "10th_percentile": 164.06, "90th_percentile": 164.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 854.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $854.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 854.5, "10th_percentile": 854.5, "90th_percentile": 854.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $854.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 683.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 683.6, "10th_percentile": 683.6, "90th_percentile": 683.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 183.72, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 183.72, "10th_percentile": 183.72, "90th_percentile": 183.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 289.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 289.68, "10th_percentile": 289.68, "90th_percentile": 289.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 427.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 427.25, "10th_percentile": 427.25, "90th_percentile": 427.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 683.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 683.6, "10th_percentile": 683.6, "90th_percentile": 683.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 512.7, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 512.7, "10th_percentile": 512.7, "90th_percentile": 512.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 640.88, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 640.88, "10th_percentile": 640.88, "90th_percentile": 640.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 854.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 854.5, "10th_percentile": 854.5, "90th_percentile": 854.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 726.33, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 726.33, "10th_percentile": 726.33, "90th_percentile": 726.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 598.15, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 598.15, "10th_percentile": 598.15, "90th_percentile": 598.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 427.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 427.25, "10th_percentile": 427.25, "90th_percentile": 427.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 640.88, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 640.88, "10th_percentile": 640.88, "90th_percentile": 640.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" } ] } ] }, { "description": "ARIPIPRAZOLE 2 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-70306", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "50268-0087-12", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.56, "maximum": 4.0, "setting": "outpatient", "gross_charge": 4.0, "discounted_cash": 2.8, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.86, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.86, "10th_percentile": 0.86, "90th_percentile": 0.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 1.36, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 1.36, "10th_percentile": 1.36, "90th_percentile": 1.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1.57, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.57, "10th_percentile": 1.57, "90th_percentile": 1.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1.77, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.77, "10th_percentile": 1.77, "90th_percentile": 1.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 2.27, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.27, "10th_percentile": 2.27, "90th_percentile": 2.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4.0, "10th_percentile": 4.0, "90th_percentile": 4.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4.0, "10th_percentile": 4.0, "90th_percentile": 4.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4.0, "10th_percentile": 4.0, "90th_percentile": 4.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4.0, "10th_percentile": 4.0, "90th_percentile": 4.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4.0, "10th_percentile": 4.0, "90th_percentile": 4.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4.0, "10th_percentile": 4.0, "90th_percentile": 4.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4.0, "10th_percentile": 4.0, "90th_percentile": 4.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4.0, "10th_percentile": 4.0, "90th_percentile": 4.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4.0, "10th_percentile": 4.0, "90th_percentile": 4.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 2.8, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 2.8, "10th_percentile": 2.8, "90th_percentile": 2.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 3.0, "10th_percentile": 3.0, "90th_percentile": 3.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 2.57, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 2.57, "10th_percentile": 2.57, "90th_percentile": 2.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.75, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.75, "10th_percentile": 0.75, "90th_percentile": 0.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 2.4, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 2.4, "10th_percentile": 2.4, "90th_percentile": 2.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 1.81, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.81, "10th_percentile": 1.81, "90th_percentile": 1.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.2, "10th_percentile": 3.2, "90th_percentile": 3.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 2.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 2.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 3.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 3.0, "10th_percentile": 3.0, "90th_percentile": 3.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 2.04, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.04, "10th_percentile": 2.04, "90th_percentile": 2.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 4.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 4.0, "10th_percentile": 4.0, "90th_percentile": 4.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 3.4, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 3.4, "10th_percentile": 3.4, "90th_percentile": 3.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 3.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 3.2, "10th_percentile": 3.2, "90th_percentile": 3.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 1.18, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.18, "10th_percentile": 1.18, "90th_percentile": 1.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 4.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $4.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 4.0, "10th_percentile": 4.0, "90th_percentile": 4.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $4.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1.57, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.57, "10th_percentile": 1.57, "90th_percentile": 1.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.68, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.68, "10th_percentile": 0.68, "90th_percentile": 0.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.57, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.57, "10th_percentile": 0.57, "90th_percentile": 0.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.56, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.56, "10th_percentile": 0.56, "90th_percentile": 0.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1.77, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.77, "10th_percentile": 1.77, "90th_percentile": 1.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 2.27, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.27, "10th_percentile": 2.27, "90th_percentile": 2.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4.0, "10th_percentile": 4.0, "90th_percentile": 4.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 4.0, "10th_percentile": 4.0, "90th_percentile": 4.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "ARIPIPRAZOLE 5 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-36438", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "16729-0279-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.89, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.89, "10th_percentile": 0.89, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.89, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.89, "10th_percentile": 0.89, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1.7, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1.7, "10th_percentile": 1.7, "90th_percentile": 1.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1.2, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1.2, "10th_percentile": 1.2, "90th_percentile": 1.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1.28, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1.28, "10th_percentile": 1.28, "90th_percentile": 1.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1.4, "10th_percentile": 1.4, "90th_percentile": 1.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.29, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.29, "10th_percentile": 0.29, "90th_percentile": 0.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 0.91, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.91, "10th_percentile": 0.91, "90th_percentile": 0.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1.02, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.02, "10th_percentile": 1.02, "90th_percentile": 1.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.59, "10th_percentile": 0.59, "90th_percentile": 0.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.28, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.28, "10th_percentile": 0.28, "90th_percentile": 0.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.37, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.37, "10th_percentile": 0.37, "90th_percentile": 0.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.68, "10th_percentile": 0.68, "90th_percentile": 0.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.43, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.34, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.34, "10th_percentile": 0.34, "90th_percentile": 0.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "ARTHREX PASSPORT BUTTON CANNULA ARTHSCP 10MMX4CM AR-6592-10-40", "code_information": [ { "code": "SUP-135669", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 10.72, "maximum": 76.64, "setting": "outpatient", "gross_charge": 76.64, "discounted_cash": 53.65, "payers_information": [ { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 53.65, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 53.65, "10th_percentile": 53.65, "90th_percentile": 53.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 38.32, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 38.32, "10th_percentile": 38.32, "90th_percentile": 38.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 45.98, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 45.98, "10th_percentile": 45.98, "90th_percentile": 45.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 49.23, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 49.23, "10th_percentile": 49.23, "90th_percentile": 49.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 76.64, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 76.64, "10th_percentile": 76.64, "90th_percentile": 76.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 34.72, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 34.72, "10th_percentile": 34.72, "90th_percentile": 34.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 39.16, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.16, "10th_percentile": 39.16, "90th_percentile": 39.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 76.64, "10th_percentile": 76.64, "90th_percentile": 76.64, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 76.64, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 76.64, "10th_percentile": 76.64, "90th_percentile": 76.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 76.64, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 76.64, "10th_percentile": 76.64, "90th_percentile": 76.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 12.98, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.98, "10th_percentile": 12.98, "90th_percentile": 12.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 33.94, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33.94, "10th_percentile": 33.94, "90th_percentile": 33.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 29.99, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 29.99, "10th_percentile": 29.99, "90th_percentile": 29.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 10.94, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.94, "10th_percentile": 10.94, "90th_percentile": 10.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 10.72, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.72, "10th_percentile": 10.72, "90th_percentile": 10.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 76.64, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $76.64 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 76.64, "10th_percentile": 76.64, "90th_percentile": 76.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $76.64 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 65.14, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 65.14, "10th_percentile": 65.14, "90th_percentile": 65.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 25.98, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 25.98, "10th_percentile": 25.98, "90th_percentile": 25.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 57.48, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 57.48, "10th_percentile": 57.48, "90th_percentile": 57.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 33.94, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33.94, "10th_percentile": 33.94, "90th_percentile": 33.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 38.32, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.32, "10th_percentile": 38.32, "90th_percentile": 38.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 61.31, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 61.31, "10th_percentile": 61.31, "90th_percentile": 61.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 16.48, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 16.48, "10th_percentile": 16.48, "90th_percentile": 16.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 29.99, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 29.99, "10th_percentile": 29.99, "90th_percentile": 29.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 57.48, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 57.48, "10th_percentile": 57.48, "90th_percentile": 57.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 22.69, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22.69, "10th_percentile": 22.69, "90th_percentile": 22.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 14.33, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.33, "10th_percentile": 14.33, "90th_percentile": 14.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 61.31, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 61.31, "10th_percentile": 61.31, "90th_percentile": 61.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 43.53, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 43.53, "10th_percentile": 43.53, "90th_percentile": 43.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 43.53, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 43.53, "10th_percentile": 43.53, "90th_percentile": 43.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 76.64, "10th_percentile": 76.64, "90th_percentile": 76.64, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 76.64, "10th_percentile": 76.64, "90th_percentile": 76.64, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 76.64, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 76.64, "10th_percentile": 76.64, "90th_percentile": 76.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 76.64, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 76.64, "10th_percentile": 76.64, "90th_percentile": 76.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 76.64, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 76.64, "10th_percentile": 76.64, "90th_percentile": 76.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 76.64, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 76.64, "10th_percentile": 76.64, "90th_percentile": 76.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 76.64, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 76.64, "10th_percentile": 76.64, "90th_percentile": 76.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 76.64, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 76.64, "10th_percentile": 76.64, "90th_percentile": 76.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "ARTHROSCOPIC SLINGSHOT 70 UP MED DEVICE STRYKER CAT02590", "code_information": [ { "code": "SUP-192871", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 98.34, "maximum": 702.96, "setting": "outpatient", "gross_charge": 702.96, "discounted_cash": 492.07, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 275.07, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 275.07, "10th_percentile": 275.07, "90th_percentile": 275.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 275.07, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 275.07, "10th_percentile": 275.07, "90th_percentile": 275.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 311.27, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 311.27, "10th_percentile": 311.27, "90th_percentile": 311.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 311.27, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 311.27, "10th_percentile": 311.27, "90th_percentile": 311.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 399.28, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 399.28, "10th_percentile": 399.28, "90th_percentile": 399.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 399.28, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 399.28, "10th_percentile": 399.28, "90th_percentile": 399.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 527.22, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 527.22, "10th_percentile": 527.22, "90th_percentile": 527.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 151.14, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 151.14, "10th_percentile": 151.14, "90th_percentile": 151.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 238.3, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 238.3, "10th_percentile": 238.3, "90th_percentile": 238.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 527.22, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 527.22, "10th_percentile": 527.22, "90th_percentile": 527.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 351.48, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 351.48, "10th_percentile": 351.48, "90th_percentile": 351.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 562.37, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 562.37, "10th_percentile": 562.37, "90th_percentile": 562.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 131.45, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 131.45, "10th_percentile": 131.45, "90th_percentile": 131.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 562.37, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 562.37, "10th_percentile": 562.37, "90th_percentile": 562.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 208.08, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 208.08, "10th_percentile": 208.08, "90th_percentile": 208.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 702.96, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $702.96 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 702.96, "10th_percentile": 702.96, "90th_percentile": 702.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $702.96 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 119.01, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 119.01, "10th_percentile": 119.01, "90th_percentile": 119.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 98.34, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 98.34, "10th_percentile": 98.34, "90th_percentile": 98.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 100.31, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 100.31, "10th_percentile": 100.31, "90th_percentile": 100.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 702.96, "10th_percentile": 702.96, "90th_percentile": 702.96, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 702.96, "10th_percentile": 702.96, "90th_percentile": 702.96, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 702.96, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 702.96, "10th_percentile": 702.96, "90th_percentile": 702.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 702.96, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 702.96, "10th_percentile": 702.96, "90th_percentile": 702.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 702.96, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 702.96, "10th_percentile": 702.96, "90th_percentile": 702.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 702.96, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 702.96, "10th_percentile": 702.96, "90th_percentile": 702.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 702.96, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 702.96, "10th_percentile": 702.96, "90th_percentile": 702.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 597.52, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 597.52, "10th_percentile": 597.52, "90th_percentile": 597.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 451.51, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 451.51, "10th_percentile": 451.51, "90th_percentile": 451.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 351.48, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 351.48, "10th_percentile": 351.48, "90th_percentile": 351.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 492.07, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 492.07, "10th_percentile": 492.07, "90th_percentile": 492.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 421.78, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 421.78, "10th_percentile": 421.78, "90th_percentile": 421.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 702.96, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 702.96, "10th_percentile": 702.96, "90th_percentile": 702.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 318.44, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 318.44, "10th_percentile": 318.44, "90th_percentile": 318.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 359.21, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 359.21, "10th_percentile": 359.21, "90th_percentile": 359.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 702.96, "10th_percentile": 702.96, "90th_percentile": 702.96, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 702.96, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 702.96, "10th_percentile": 702.96, "90th_percentile": 702.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 702.96, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 702.96, "10th_percentile": 702.96, "90th_percentile": 702.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 702.96, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 702.96, "10th_percentile": 702.96, "90th_percentile": 702.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "ARTICULATION KT TOT ELB NEXEL SZ 4", "code_information": [ { "code": "SUP-159473", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 266.46, "maximum": 1665.37, "setting": "outpatient", "gross_charge": 1665.37, "discounted_cash": 1165.76, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 851.0, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2248.51, "10th_percentile": 2248.51, "90th_percentile": 2248.51, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 266.46, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 266.46, "10th_percentile": 266.46, "90th_percentile": 266.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 266.46, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 266.46, "10th_percentile": 266.46, "90th_percentile": 266.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 266.46, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 266.46, "10th_percentile": 266.46, "90th_percentile": 266.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 945.93, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 945.93, "10th_percentile": 945.93, "90th_percentile": 945.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 945.93, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 945.93, "10th_percentile": 945.93, "90th_percentile": 945.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1665.37, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,665.37 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1665.37, "10th_percentile": 1665.37, "90th_percentile": 1665.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,665.37 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 492.95, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 492.95, "10th_percentile": 492.95, "90th_percentile": 492.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1665.37, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1665.37, "10th_percentile": 1665.37, "90th_percentile": 1665.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1249.03, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1249.03, "10th_percentile": 1249.03, "90th_percentile": 1249.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 564.56, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 564.56, "10th_percentile": 564.56, "90th_percentile": 564.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1332.3, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1332.3, "10th_percentile": 1332.3, "90th_percentile": 1332.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1249.03, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1249.03, "10th_percentile": 1249.03, "90th_percentile": 1249.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 358.05, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 358.05, "10th_percentile": 358.05, "90th_percentile": 358.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1069.67, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1069.67, "10th_percentile": 1069.67, "90th_percentile": 1069.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 832.69, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 832.69, "10th_percentile": 832.69, "90th_percentile": 832.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1332.3, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1332.3, "10th_percentile": 1332.3, "90th_percentile": 1332.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 754.41, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 754.41, "10th_percentile": 754.41, "90th_percentile": 754.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1165.76, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1165.76, "10th_percentile": 1165.76, "90th_percentile": 1165.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 999.22, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 999.22, "10th_percentile": 999.22, "90th_percentile": 999.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1415.56, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1415.56, "10th_percentile": 1415.56, "90th_percentile": 1415.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 832.69, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 832.69, "10th_percentile": 832.69, "90th_percentile": 832.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 311.42, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 311.42, "10th_percentile": 311.42, "90th_percentile": 311.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 651.66, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 651.66, "10th_percentile": 651.66, "90th_percentile": 651.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 651.66, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 651.66, "10th_percentile": 651.66, "90th_percentile": 651.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 319.75, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 319.75, "10th_percentile": 319.75, "90th_percentile": 319.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 319.75, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 319.75, "10th_percentile": 319.75, "90th_percentile": 319.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1665.37, "10th_percentile": 1665.37, "90th_percentile": 1665.37, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1665.37, "10th_percentile": 1665.37, "90th_percentile": 1665.37, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1665.37, "10th_percentile": 1665.37, "90th_percentile": 1665.37, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1665.37, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1665.37, "10th_percentile": 1665.37, "90th_percentile": 1665.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1665.37, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1665.37, "10th_percentile": 1665.37, "90th_percentile": 1665.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1665.37, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1665.37, "10th_percentile": 1665.37, "90th_percentile": 1665.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1665.37, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1665.37, "10th_percentile": 1665.37, "90th_percentile": 1665.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1665.37, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1665.37, "10th_percentile": 1665.37, "90th_percentile": 1665.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1665.37, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1665.37, "10th_percentile": 1665.37, "90th_percentile": 1665.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1665.37, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1665.37, "10th_percentile": 1665.37, "90th_percentile": 1665.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1665.37, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1665.37, "10th_percentile": 1665.37, "90th_percentile": 1665.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "ASCORBIC ACID (VITAMIN C) 250 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-663", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "50268-0860-15", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.89, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.89, "10th_percentile": 0.89, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.89, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.89, "10th_percentile": 0.89, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.68, "10th_percentile": 0.68, "90th_percentile": 0.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.28, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.28, "10th_percentile": 0.28, "90th_percentile": 0.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.43, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.34, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.34, "10th_percentile": 0.34, "90th_percentile": 0.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.37, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.37, "10th_percentile": 0.37, "90th_percentile": 0.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.29, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.29, "10th_percentile": 0.29, "90th_percentile": 0.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1.7, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1.7, "10th_percentile": 1.7, "90th_percentile": 1.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.59, "10th_percentile": 0.59, "90th_percentile": 0.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1.2, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1.2, "10th_percentile": 1.2, "90th_percentile": 1.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1.28, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1.28, "10th_percentile": 1.28, "90th_percentile": 1.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1.4, "10th_percentile": 1.4, "90th_percentile": 1.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 0.91, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.91, "10th_percentile": 0.91, "90th_percentile": 0.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1.02, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.02, "10th_percentile": 1.02, "90th_percentile": 1.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "ATENOLOL 25 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-717", "type": "CDM" }, { "code": "J3490", "type": "HCPCS" }, { "code": "0637", "type": "RC" }, { "code": "00093-0787-10", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.32, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1.4, "10th_percentile": 1.4, "90th_percentile": 1.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1.2, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1.2, "10th_percentile": 1.2, "90th_percentile": 1.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1.02, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.02, "10th_percentile": 1.02, "90th_percentile": 1.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1.28, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1.28, "10th_percentile": 1.28, "90th_percentile": 1.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1.7, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1.7, "10th_percentile": 1.7, "90th_percentile": 1.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 0.91, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.91, "10th_percentile": 0.91, "90th_percentile": 0.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.43, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.68, "10th_percentile": 0.68, "90th_percentile": 0.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.38, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.38, "10th_percentile": 0.38, "90th_percentile": 0.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.38, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.38, "10th_percentile": 0.38, "90th_percentile": 0.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.32, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.32, "10th_percentile": 0.32, "90th_percentile": 0.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.32, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.32, "10th_percentile": 0.32, "90th_percentile": 0.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.32, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.32, "10th_percentile": 0.32, "90th_percentile": 0.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "ATENOLOL 25 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-717", "type": "CDM" }, { "code": "J3490", "type": "HCPCS" }, { "code": "0637", "type": "RC" }, { "code": "60687-0605-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.32, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.32, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.32, "10th_percentile": 0.32, "90th_percentile": 0.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.32, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.32, "10th_percentile": 0.32, "90th_percentile": 0.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.32, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.32, "10th_percentile": 0.32, "90th_percentile": 0.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.38, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.38, "10th_percentile": 0.38, "90th_percentile": 0.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.38, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.38, "10th_percentile": 0.38, "90th_percentile": 0.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1.2, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1.2, "10th_percentile": 1.2, "90th_percentile": 1.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1.02, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.02, "10th_percentile": 1.02, "90th_percentile": 1.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1.28, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1.28, "10th_percentile": 1.28, "90th_percentile": 1.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 0.91, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.91, "10th_percentile": 0.91, "90th_percentile": 0.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.43, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.68, "10th_percentile": 0.68, "90th_percentile": 0.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1.4, "10th_percentile": 1.4, "90th_percentile": 1.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1.7, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1.7, "10th_percentile": 1.7, "90th_percentile": 1.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" } ] } ] }, { "description": "ATENOLOL 25 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-717", "type": "CDM" }, { "code": "J3490", "type": "HCPCS" }, { "code": "0637", "type": "RC" }, { "code": "60687-0605-11", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.32, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1.4, "10th_percentile": 1.4, "90th_percentile": 1.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1.2, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1.2, "10th_percentile": 1.2, "90th_percentile": 1.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1.02, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.02, "10th_percentile": 1.02, "90th_percentile": 1.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1.28, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1.28, "10th_percentile": 1.28, "90th_percentile": 1.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1.7, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1.7, "10th_percentile": 1.7, "90th_percentile": 1.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 0.91, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.91, "10th_percentile": 0.91, "90th_percentile": 0.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.38, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.38, "10th_percentile": 0.38, "90th_percentile": 0.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.32, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.32, "10th_percentile": 0.32, "90th_percentile": 0.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.32, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.32, "10th_percentile": 0.32, "90th_percentile": 0.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.32, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.32, "10th_percentile": 0.32, "90th_percentile": 0.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.38, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.38, "10th_percentile": 0.38, "90th_percentile": 0.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.43, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.68, "10th_percentile": 0.68, "90th_percentile": 0.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" } ] } ] }, { "description": "ATHEROSCLEROSIS WITHOUT MCC", "code_information": [ { "code": "303", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 4790.38, "maximum": 9805.16, "setting": "inpatient", "gross_charge": 26973.5, "discounted_cash": 18881.45, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_dollar": 4790.38, "standard_charge_algorithm": "Re-evaluated: HLB.686944765; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.67, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $5,086.07; Additional payment reduction: $50.86; Total: $5,035.21", "median_amount": 5035.21, "10th_percentile": 5035.21, "90th_percentile": 5035.21, "count": "12", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.686944765; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.67, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $5,086.07; Additional payment reduction: $50.86; Total: $5,035.21" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.686944765; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All IP Services; 100% Billed", "median_amount": 27001.0, "10th_percentile": 27001.0, "90th_percentile": 27001.0, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.686944765; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All IP Services; 100% Billed", "median_amount": 27001.0, "10th_percentile": 27001.0, "90th_percentile": 27001.0, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.686944765; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All IP Services; 100% Billed", "median_amount": 27001.0, "10th_percentile": 27001.0, "90th_percentile": 27001.0, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.686944765; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All IP Services; 100% Billed", "median_amount": 27001.0, "10th_percentile": 27001.0, "90th_percentile": 27001.0, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.686944765; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All IP Services; 100% Billed", "median_amount": 27001.0, "10th_percentile": 27001.0, "90th_percentile": 27001.0, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.686944765; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All IP Services; 100% Billed", "median_amount": 27001.0, "10th_percentile": 27001.0, "90th_percentile": 27001.0, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.686944765; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All IP Services; 100% Billed", "median_amount": 27001.0, "10th_percentile": 27001.0, "90th_percentile": 27001.0, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.686944765; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All IP Services - OON; 100% Billed", "median_amount": 27001.0, "10th_percentile": 27001.0, "90th_percentile": 27001.0, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Re-evaluated: HLB.686944765; Using historical claim(s); Scope: All Financial Classes; Cases: 12; INPATIENT; 80% Billed", "median_amount": 21600.8, "10th_percentile": 21600.8, "90th_percentile": 21600.8, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 30.4, "standard_charge_algorithm": "Re-evaluated: HLB.686944765; Using historical claim(s); Scope: All Financial Classes; Cases: 12; IP Services. ADP RATE (for patient estimates only); 30.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8208.3, "10th_percentile": 8208.3, "90th_percentile": 8208.3, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Additional drugs, labs, and other services can be included in reimbursement.", "median_amount": 12754.7, "10th_percentile": 12754.7, "90th_percentile": 12754.7, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, and other services can be included in reimbursement.", "median_amount": 13500.5, "10th_percentile": 13500.5, "90th_percentile": 13500.5, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Re-evaluated: HLB.686944765; Using historical claim(s); Scope: All Financial Classes; Cases: 12; Inpatient Services; 50% Billed", "median_amount": 13500.5, "10th_percentile": 13500.5, "90th_percentile": 13500.5, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, and other services can be included in reimbursement.", "median_amount": 20250.75, "10th_percentile": 20250.75, "90th_percentile": 20250.75, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Re-evaluated: HLB.686944765; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All IP Services; 75% Billed", "median_amount": 20250.75, "10th_percentile": 20250.75, "90th_percentile": 20250.75, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 9805.16, "standard_charge_algorithm": "Re-evaluated: HLB.686944765; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.6732, Rate: 14,565.00, and; Pricing Extension - NM HB XR PRC - PH BCBS PPO STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9805.16, "10th_percentile": 9805.16, "90th_percentile": 9805.16, "count": "12", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_dollar": 4790.38, "standard_charge_algorithm": "Re-evaluated: HLB.686944765; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.67, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $5,086.07; Additional payment reduction: $50.86; Total: $5,035.21", "median_amount": 5035.21, "10th_percentile": 5035.21, "90th_percentile": 5035.21, "count": "12", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.686944765; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.67, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $5,086.07; Additional payment reduction: $50.86; Total: $5,035.21" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.686944765; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All IP Services; 100% Billed", "median_amount": 27001.0, "10th_percentile": 27001.0, "90th_percentile": 27001.0, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_percentage": 34.2, "standard_charge_algorithm": "Re-evaluated: HLB.686944765; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All Inpatient Services; 34.2% Billed", "median_amount": 9234.34, "10th_percentile": 9234.34, "90th_percentile": 9234.34, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_percentage": 21.5, "standard_charge_algorithm": "Additional drugs, labs, radiology services, and other services can be included in reimbursement.", "median_amount": 5805.24, "10th_percentile": 5805.24, "90th_percentile": 5805.24, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Re-evaluated: HLB.686944765; Using historical claim(s); Scope: All Financial Classes; Cases: 12; Inpatient; 80% Billed", "median_amount": 21600.8, "10th_percentile": 21600.8, "90th_percentile": 21600.8, "count": "12", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 5388.97, "standard_charge_algorithm": "Re-evaluated: HLB.686944765; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.6732, Rate: 8,005.00, and; Pricing Extension - NM HB XR PRC - PH BCBS CHOICE SELECT STOP LOSS & LESSOR OF *; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5388.97, "10th_percentile": 5388.97, "90th_percentile": 5388.97, "count": "12", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 6089.09, "standard_charge_algorithm": "Re-evaluated: HLB.686944765; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.6732, Rate: 9,045.00, and; Pricing Extension - NM HB XR PRC - PH BCBS CHOICE STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6089.09, "10th_percentile": 6089.09, "90th_percentile": 6089.09, "count": "12", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 5765.96, "standard_charge_algorithm": "Re-evaluated: HLB.686944765; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.6732, Rate: 8,565.00, and; Pricing Extension - NM HB XR PRC - PH BCBS CHOICE PREF STOP LOSS & LESSOR OF 9.*; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5765.96, "10th_percentile": 5765.96, "90th_percentile": 5765.96, "count": "12", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 6925.21, "standard_charge_algorithm": "Re-evaluated: HLB.686944765; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.6732, Rate: 10,287.00, and; Pricing Extension - NM HB XR PRC - PH BCBS HMO STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6925.21, "10th_percentile": 6925.21, "90th_percentile": 6925.21, "count": "12", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 6925.21, "standard_charge_algorithm": "Re-evaluated: HLB.686944765; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.6732, Rate: 10,287.00, and; Pricing Extension - NM HB XR PRC - PH BCBS HMO STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6925.21, "10th_percentile": 6925.21, "90th_percentile": 6925.21, "count": "12", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 9805.16, "standard_charge_algorithm": "Re-evaluated: HLB.686944765; Using historical claim(s); Scope: All Financial Classes; Cases: 12; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.6732, Rate: 14,565.00, and; Pricing Extension - NM HB XR PRC - PH BCBS PPO STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9805.16, "10th_percentile": 9805.16, "90th_percentile": 9805.16, "count": "12", "methodology": "case rate" } ] } ] }, { "description": "ATL STAPLE CAUDAL TI", "code_information": [ { "code": "SUP-306208", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 155.78, "maximum": 973.6, "setting": "outpatient", "gross_charge": 973.6, "discounted_cash": 681.52, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 497.51, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 252.68, "10th_percentile": 252.68, "90th_percentile": 252.68, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 209.32, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 373.87, "10th_percentile": 373.87, "90th_percentile": 373.87, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 155.78, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 155.78, "10th_percentile": 155.78, "90th_percentile": 155.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 155.78, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 155.78, "10th_percentile": 155.78, "90th_percentile": 155.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 155.78, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 155.78, "10th_percentile": 155.78, "90th_percentile": 155.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 186.93, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 186.93, "10th_percentile": 186.93, "90th_percentile": 186.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 186.93, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 186.93, "10th_percentile": 186.93, "90th_percentile": 186.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 553.0, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 553.0, "10th_percentile": 553.0, "90th_percentile": 553.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 553.0, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 553.0, "10th_percentile": 553.0, "90th_percentile": 553.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 380.97, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 380.97, "10th_percentile": 380.97, "90th_percentile": 380.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 380.97, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 380.97, "10th_percentile": 380.97, "90th_percentile": 380.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 288.19, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.51, "10th_percentile": 5.51, "90th_percentile": 5.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 730.2, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 730.2, "10th_percentile": 730.2, "90th_percentile": 730.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 778.88, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 778.88, "10th_percentile": 778.88, "90th_percentile": 778.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 625.34, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 625.34, "10th_percentile": 625.34, "90th_percentile": 625.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 973.6, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $973.60 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 973.6, "10th_percentile": 973.6, "90th_percentile": 973.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $973.60 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 486.8, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 486.8, "10th_percentile": 486.8, "90th_percentile": 486.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 778.88, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 778.88, "10th_percentile": 778.88, "90th_percentile": 778.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 441.04, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 441.04, "10th_percentile": 441.04, "90th_percentile": 441.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 486.8, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 486.8, "10th_percentile": 486.8, "90th_percentile": 486.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 827.56, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 827.56, "10th_percentile": 827.56, "90th_percentile": 827.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 681.52, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 681.52, "10th_percentile": 681.52, "90th_percentile": 681.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 330.05, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 330.05, "10th_percentile": 330.05, "90th_percentile": 330.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 973.6, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 973.6, "10th_percentile": 973.6, "90th_percentile": 973.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 584.16, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 584.16, "10th_percentile": 584.16, "90th_percentile": 584.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 730.2, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 730.2, "10th_percentile": 730.2, "90th_percentile": 730.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 182.06, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 182.06, "10th_percentile": 182.06, "90th_percentile": 182.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 973.6, "10th_percentile": 973.6, "90th_percentile": 973.6, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 973.6, "10th_percentile": 973.6, "90th_percentile": 973.6, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 973.6, "10th_percentile": 973.6, "90th_percentile": 973.6, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 973.6, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 973.6, "10th_percentile": 973.6, "90th_percentile": 973.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 973.6, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 973.6, "10th_percentile": 973.6, "90th_percentile": 973.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 973.6, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 973.6, "10th_percentile": 973.6, "90th_percentile": 973.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 973.6, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 973.6, "10th_percentile": 973.6, "90th_percentile": 973.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 973.6, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 973.6, "10th_percentile": 973.6, "90th_percentile": 973.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 973.6, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 973.6, "10th_percentile": 973.6, "90th_percentile": 973.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 973.6, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 973.6, "10th_percentile": 973.6, "90th_percentile": 973.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 973.6, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 973.6, "10th_percentile": 973.6, "90th_percentile": 973.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "ATOVAQUONE 750 MG/5 ML ORAL SUSP", "drug_information": { "unit": 5.0, "type": "ML" }, "code_information": [ { "code": "RX-14953", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "00121-1016-18", "type": "NDC" } ], "standard_charges": [ { "minimum": 7.2, "maximum": 51.5, "setting": "outpatient", "gross_charge": 51.5, "discounted_cash": 36.05, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 51.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 51.5, "10th_percentile": 51.5, "90th_percentile": 51.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 51.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 51.5, "10th_percentile": 51.5, "90th_percentile": 51.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 51.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 51.5, "10th_percentile": 51.5, "90th_percentile": 51.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 51.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 51.5, "10th_percentile": 51.5, "90th_percentile": 51.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 51.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 51.5, "10th_percentile": 51.5, "90th_percentile": 51.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 51.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 51.5, "10th_percentile": 51.5, "90th_percentile": 51.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 51.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 51.5, "10th_percentile": 51.5, "90th_percentile": 51.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 51.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 51.5, "10th_percentile": 51.5, "90th_percentile": 51.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 29.25, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 29.25, "10th_percentile": 29.25, "90th_percentile": 29.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 17.46, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 17.46, "10th_percentile": 17.46, "90th_percentile": 17.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 11.07, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 11.07, "10th_percentile": 11.07, "90th_percentile": 11.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 20.15, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.15, "10th_percentile": 20.15, "90th_percentile": 20.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 22.8, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22.8, "10th_percentile": 22.8, "90th_percentile": 22.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 41.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 41.2, "10th_percentile": 41.2, "90th_percentile": 41.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 8.72, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.72, "10th_percentile": 8.72, "90th_percentile": 8.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 7.2, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.2, "10th_percentile": 7.2, "90th_percentile": 7.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 7.35, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.35, "10th_percentile": 7.35, "90th_percentile": 7.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 20.15, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.15, "10th_percentile": 20.15, "90th_percentile": 20.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 51.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $51.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 51.5, "10th_percentile": 51.5, "90th_percentile": 51.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $51.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 22.8, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22.8, "10th_percentile": 22.8, "90th_percentile": 22.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 25.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.75, "10th_percentile": 25.75, "90th_percentile": 25.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 9.63, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.63, "10th_percentile": 9.63, "90th_percentile": 9.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 41.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 41.2, "10th_percentile": 41.2, "90th_percentile": 41.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 15.24, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15.24, "10th_percentile": 15.24, "90th_percentile": 15.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 38.63, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 38.63, "10th_percentile": 38.63, "90th_percentile": 38.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 29.25, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 29.25, "10th_percentile": 29.25, "90th_percentile": 29.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 38.63, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 38.63, "10th_percentile": 38.63, "90th_percentile": 38.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 43.78, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 43.78, "10th_percentile": 43.78, "90th_percentile": 43.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 25.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 25.75, "10th_percentile": 25.75, "90th_percentile": 25.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 30.9, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 30.9, "10th_percentile": 30.9, "90th_percentile": 30.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 36.05, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 36.05, "10th_percentile": 36.05, "90th_percentile": 36.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 33.08, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 33.08, "10th_percentile": 33.08, "90th_percentile": 33.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 26.32, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 26.32, "10th_percentile": 26.32, "90th_percentile": 26.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 23.33, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 23.33, "10th_percentile": 23.33, "90th_percentile": 23.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 51.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 51.5, "10th_percentile": 51.5, "90th_percentile": 51.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 51.5, "10th_percentile": 51.5, "90th_percentile": 51.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 51.5, "10th_percentile": 51.5, "90th_percentile": 51.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 51.5, "10th_percentile": 51.5, "90th_percentile": 51.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "ATROPINE 0.1 MG/ML INJ SYRG", "drug_information": { "unit": 10.0, "type": "ML" }, "code_information": [ { "code": "RX-730", "type": "CDM" }, { "code": "J0461", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "00409-1630-10", "type": "NDC" } ], "standard_charges": [ { "minimum": 8.08, "maximum": 50.5, "setting": "outpatient", "gross_charge": 50.5, "discounted_cash": 35.35, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 50.5, "10th_percentile": 50.5, "90th_percentile": 50.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 50.5, "10th_percentile": 50.5, "90th_percentile": 50.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 50.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $50.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 50.5, "10th_percentile": 50.5, "90th_percentile": 50.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $50.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 40.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 40.4, "10th_percentile": 40.4, "90th_percentile": 40.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 25.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.25, "10th_percentile": 25.25, "90th_percentile": 25.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 40.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 40.4, "10th_percentile": 40.4, "90th_percentile": 40.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 37.88, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 37.88, "10th_percentile": 37.88, "90th_percentile": 37.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 37.88, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 37.88, "10th_percentile": 37.88, "90th_percentile": 37.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 42.93, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 42.93, "10th_percentile": 42.93, "90th_percentile": 42.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 25.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 25.25, "10th_percentile": 25.25, "90th_percentile": 25.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 30.3, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 30.3, "10th_percentile": 30.3, "90th_percentile": 30.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 35.35, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 35.35, "10th_percentile": 35.35, "90th_percentile": 35.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 50.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 50.5, "10th_percentile": 50.5, "90th_percentile": 50.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 9.7, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.7, "10th_percentile": 9.7, "90th_percentile": 9.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 9.7, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.7, "10th_percentile": 9.7, "90th_percentile": 9.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 19.76, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.76, "10th_percentile": 19.76, "90th_percentile": 19.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 8.08, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.08, "10th_percentile": 8.08, "90th_percentile": 8.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 8.08, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.08, "10th_percentile": 8.08, "90th_percentile": 8.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 8.08, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.08, "10th_percentile": 8.08, "90th_percentile": 8.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 50.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 50.5, "10th_percentile": 50.5, "90th_percentile": 50.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 50.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 50.5, "10th_percentile": 50.5, "90th_percentile": 50.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 50.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 50.5, "10th_percentile": 50.5, "90th_percentile": 50.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 50.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 50.5, "10th_percentile": 50.5, "90th_percentile": 50.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 50.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 50.5, "10th_percentile": 50.5, "90th_percentile": 50.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 50.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 50.5, "10th_percentile": 50.5, "90th_percentile": 50.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 50.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 50.5, "10th_percentile": 50.5, "90th_percentile": 50.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 50.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 50.5, "10th_percentile": 50.5, "90th_percentile": 50.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 50.5, "10th_percentile": 50.5, "90th_percentile": 50.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 19.76, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.76, "10th_percentile": 19.76, "90th_percentile": 19.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 10.86, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 10.86, "10th_percentile": 10.86, "90th_percentile": 10.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 17.12, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 17.12, "10th_percentile": 17.12, "90th_percentile": 17.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" } ] } ] }, { "description": "ATROPINE 1 % OPHT DROP", "drug_information": { "unit": 2.0, "type": "ML" }, "code_information": [ { "code": "RX-736", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "60219-1748-02", "type": "NDC" } ], "standard_charges": [ { "minimum": 24.59, "maximum": 175.75, "setting": "outpatient", "gross_charge": 175.75, "discounted_cash": 123.02, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 175.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 175.75, "10th_percentile": 175.75, "90th_percentile": 175.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 112.88, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 112.88, "10th_percentile": 112.88, "90th_percentile": 112.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 89.81, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 89.81, "10th_percentile": 89.81, "90th_percentile": 89.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 79.61, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 79.61, "10th_percentile": 79.61, "90th_percentile": 79.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 175.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 175.75, "10th_percentile": 175.75, "90th_percentile": 175.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 175.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 175.75, "10th_percentile": 175.75, "90th_percentile": 175.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 175.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 175.75, "10th_percentile": 175.75, "90th_percentile": 175.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 175.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 175.75, "10th_percentile": 175.75, "90th_percentile": 175.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 175.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 175.75, "10th_percentile": 175.75, "90th_percentile": 175.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 175.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 175.75, "10th_percentile": 175.75, "90th_percentile": 175.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 175.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 175.75, "10th_percentile": 175.75, "90th_percentile": 175.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 175.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 175.75, "10th_percentile": 175.75, "90th_percentile": 175.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 131.81, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 131.81, "10th_percentile": 131.81, "90th_percentile": 131.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 32.87, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 32.87, "10th_percentile": 32.87, "90th_percentile": 32.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 140.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 140.6, "10th_percentile": 140.6, "90th_percentile": 140.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 105.45, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 105.45, "10th_percentile": 105.45, "90th_percentile": 105.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 149.39, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 149.39, "10th_percentile": 149.39, "90th_percentile": 149.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 37.79, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 37.79, "10th_percentile": 37.79, "90th_percentile": 37.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 131.81, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 131.81, "10th_percentile": 131.81, "90th_percentile": 131.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 59.58, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 59.58, "10th_percentile": 59.58, "90th_percentile": 59.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 52.02, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 52.02, "10th_percentile": 52.02, "90th_percentile": 52.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 123.03, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 123.03, "10th_percentile": 123.03, "90th_percentile": 123.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 140.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 140.6, "10th_percentile": 140.6, "90th_percentile": 140.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 87.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 87.88, "10th_percentile": 87.88, "90th_percentile": 87.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 87.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 87.88, "10th_percentile": 87.88, "90th_percentile": 87.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 175.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $175.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 175.75, "10th_percentile": 175.75, "90th_percentile": 175.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $175.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 25.08, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.08, "10th_percentile": 25.08, "90th_percentile": 25.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 24.59, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.59, "10th_percentile": 24.59, "90th_percentile": 24.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 29.75, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 29.75, "10th_percentile": 29.75, "90th_percentile": 29.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 99.83, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 99.83, "10th_percentile": 99.83, "90th_percentile": 99.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 99.83, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 99.83, "10th_percentile": 99.83, "90th_percentile": 99.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 68.77, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 68.77, "10th_percentile": 68.77, "90th_percentile": 68.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 68.77, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 68.77, "10th_percentile": 68.77, "90th_percentile": 68.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 77.82, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 77.82, "10th_percentile": 77.82, "90th_percentile": 77.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 77.82, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 77.82, "10th_percentile": 77.82, "90th_percentile": 77.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 175.75, "10th_percentile": 175.75, "90th_percentile": 175.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 175.75, "10th_percentile": 175.75, "90th_percentile": 175.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 175.75, "10th_percentile": 175.75, "90th_percentile": 175.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "ATROPINE 1 % OPHT DROP", "drug_information": { "unit": 5.0, "type": "ML" }, "code_information": [ { "code": "RX-736", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "60505-6226-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 33.02, "maximum": 236.0, "setting": "outpatient", "gross_charge": 236.0, "discounted_cash": 165.2, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 236.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 236.0, "10th_percentile": 236.0, "90th_percentile": 236.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 236.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 236.0, "10th_percentile": 236.0, "90th_percentile": 236.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 236.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 236.0, "10th_percentile": 236.0, "90th_percentile": 236.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 236.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 236.0, "10th_percentile": 236.0, "90th_percentile": 236.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 236.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 236.0, "10th_percentile": 236.0, "90th_percentile": 236.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 134.05, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 134.05, "10th_percentile": 134.05, "90th_percentile": 134.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 80.0, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 80.0, "10th_percentile": 80.0, "90th_percentile": 80.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 50.74, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 50.74, "10th_percentile": 50.74, "90th_percentile": 50.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 92.35, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 92.35, "10th_percentile": 92.35, "90th_percentile": 92.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 104.5, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 104.5, "10th_percentile": 104.5, "90th_percentile": 104.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 188.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 188.8, "10th_percentile": 188.8, "90th_percentile": 188.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 39.95, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.95, "10th_percentile": 39.95, "90th_percentile": 39.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 33.02, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33.02, "10th_percentile": 33.02, "90th_percentile": 33.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 33.68, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33.68, "10th_percentile": 33.68, "90th_percentile": 33.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 92.35, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 92.35, "10th_percentile": 92.35, "90th_percentile": 92.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 236.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $236.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 236.0, "10th_percentile": 236.0, "90th_percentile": 236.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $236.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 104.5, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 104.5, "10th_percentile": 104.5, "90th_percentile": 104.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 118.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 118.0, "10th_percentile": 118.0, "90th_percentile": 118.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 44.13, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 44.13, "10th_percentile": 44.13, "90th_percentile": 44.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 188.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 188.8, "10th_percentile": 188.8, "90th_percentile": 188.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 69.86, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 69.86, "10th_percentile": 69.86, "90th_percentile": 69.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 177.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 177.0, "10th_percentile": 177.0, "90th_percentile": 177.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 134.05, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 134.05, "10th_percentile": 134.05, "90th_percentile": 134.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 177.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 177.0, "10th_percentile": 177.0, "90th_percentile": 177.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 200.6, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 200.6, "10th_percentile": 200.6, "90th_percentile": 200.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 236.0, "10th_percentile": 236.0, "90th_percentile": 236.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 236.0, "10th_percentile": 236.0, "90th_percentile": 236.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 236.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 236.0, "10th_percentile": 236.0, "90th_percentile": 236.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 236.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 236.0, "10th_percentile": 236.0, "90th_percentile": 236.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 236.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 236.0, "10th_percentile": 236.0, "90th_percentile": 236.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 118.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 118.0, "10th_percentile": 118.0, "90th_percentile": 118.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 141.6, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 141.6, "10th_percentile": 141.6, "90th_percentile": 141.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 165.2, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 165.2, "10th_percentile": 165.2, "90th_percentile": 165.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 151.58, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 151.58, "10th_percentile": 151.58, "90th_percentile": 151.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 120.6, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 120.6, "10th_percentile": 120.6, "90th_percentile": 120.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 106.91, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 106.91, "10th_percentile": 106.91, "90th_percentile": 106.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 236.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 236.0, "10th_percentile": 236.0, "90th_percentile": 236.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 236.0, "10th_percentile": 236.0, "90th_percentile": 236.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "ATTAIN COMMAND EXTENDED HOOK", "code_information": [ { "code": "SUP-148243", "type": "CDM" }, { "code": "C1887", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 76.64, "maximum": 479.0, "setting": "outpatient", "gross_charge": 479.0, "discounted_cash": 335.3, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 479.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 479.0, "10th_percentile": 479.0, "90th_percentile": 479.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 479.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 479.0, "10th_percentile": 479.0, "90th_percentile": 479.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 479.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 479.0, "10th_percentile": 479.0, "90th_percentile": 479.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 479.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 479.0, "10th_percentile": 479.0, "90th_percentile": 479.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 479.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 479.0, "10th_percentile": 479.0, "90th_percentile": 479.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 479.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 479.0, "10th_percentile": 479.0, "90th_percentile": 479.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 479.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 479.0, "10th_percentile": 479.0, "90th_percentile": 479.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 479.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 479.0, "10th_percentile": 479.0, "90th_percentile": 479.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 141.78, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 31.07, "10th_percentile": 31.07, "90th_percentile": 31.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 479.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $479.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 479.0, "10th_percentile": 479.0, "90th_percentile": 479.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $479.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 102.99, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 102.99, "10th_percentile": 102.99, "90th_percentile": 102.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 162.38, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 162.38, "10th_percentile": 162.38, "90th_percentile": 162.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 239.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 239.5, "10th_percentile": 239.5, "90th_percentile": 239.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 359.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 359.25, "10th_percentile": 359.25, "90th_percentile": 359.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 383.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 383.2, "10th_percentile": 383.2, "90th_percentile": 383.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 307.66, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 307.66, "10th_percentile": 307.66, "90th_percentile": 307.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 335.3, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 335.3, "10th_percentile": 335.3, "90th_percentile": 335.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 287.4, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 287.4, "10th_percentile": 287.4, "90th_percentile": 287.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 407.15, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 407.15, "10th_percentile": 407.15, "90th_percentile": 407.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 359.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 359.25, "10th_percentile": 359.25, "90th_percentile": 359.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 383.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 383.2, "10th_percentile": 383.2, "90th_percentile": 383.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 89.57, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 89.57, "10th_percentile": 89.57, "90th_percentile": 89.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 479.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 479.0, "10th_percentile": 479.0, "90th_percentile": 479.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 216.99, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 216.99, "10th_percentile": 216.99, "90th_percentile": 216.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 239.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 239.5, "10th_percentile": 239.5, "90th_percentile": 239.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 244.77, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 244.77, "10th_percentile": 244.77, "90th_percentile": 244.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 187.43, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 187.43, "10th_percentile": 187.43, "90th_percentile": 187.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 187.43, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 187.43, "10th_percentile": 187.43, "90th_percentile": 187.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 91.97, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 91.97, "10th_percentile": 91.97, "90th_percentile": 91.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 91.97, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 91.97, "10th_percentile": 91.97, "90th_percentile": 91.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 272.07, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 272.07, "10th_percentile": 272.07, "90th_percentile": 272.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 272.07, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 272.07, "10th_percentile": 272.07, "90th_percentile": 272.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 76.64, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 76.64, "10th_percentile": 76.64, "90th_percentile": 76.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 76.64, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 76.64, "10th_percentile": 76.64, "90th_percentile": 76.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 76.64, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 76.64, "10th_percentile": 76.64, "90th_percentile": 76.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 479.0, "10th_percentile": 479.0, "90th_percentile": 479.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 479.0, "10th_percentile": 479.0, "90th_percentile": 479.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 479.0, "10th_percentile": 479.0, "90th_percentile": 479.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "AUGMENT FEM 10MM SZ 9 DISTAL PSN REV 42556606610", "code_information": [ { "code": "SUP-345960", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 360.74, "maximum": 2254.65, "setting": "outpatient", "gross_charge": 2254.65, "discounted_cash": 1578.25, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1152.13, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2248.51, "10th_percentile": 2248.51, "90th_percentile": 2248.51, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 360.74, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 360.74, "10th_percentile": 360.74, "90th_percentile": 360.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 360.74, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 360.74, "10th_percentile": 360.74, "90th_percentile": 360.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 360.74, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 360.74, "10th_percentile": 360.74, "90th_percentile": 360.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1280.64, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1280.64, "10th_percentile": 1280.64, "90th_percentile": 1280.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1280.64, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1280.64, "10th_percentile": 1280.64, "90th_percentile": 1280.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2254.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,254.65 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2254.65, "10th_percentile": 2254.65, "90th_percentile": 2254.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,254.65 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 667.38, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 667.38, "10th_percentile": 667.38, "90th_percentile": 667.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2254.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2254.65, "10th_percentile": 2254.65, "90th_percentile": 2254.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1690.99, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1690.99, "10th_percentile": 1690.99, "90th_percentile": 1690.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 764.33, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 764.33, "10th_percentile": 764.33, "90th_percentile": 764.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1803.72, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1803.72, "10th_percentile": 1803.72, "90th_percentile": 1803.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1690.99, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1690.99, "10th_percentile": 1690.99, "90th_percentile": 1690.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 484.75, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 484.75, "10th_percentile": 484.75, "90th_percentile": 484.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1448.16, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1448.16, "10th_percentile": 1448.16, "90th_percentile": 1448.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1127.33, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1127.33, "10th_percentile": 1127.33, "90th_percentile": 1127.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1803.72, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1803.72, "10th_percentile": 1803.72, "90th_percentile": 1803.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 1021.36, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1021.36, "10th_percentile": 1021.36, "90th_percentile": 1021.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1578.26, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1578.26, "10th_percentile": 1578.26, "90th_percentile": 1578.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1352.79, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1352.79, "10th_percentile": 1352.79, "90th_percentile": 1352.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1916.45, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1916.45, "10th_percentile": 1916.45, "90th_percentile": 1916.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1127.33, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1127.33, "10th_percentile": 1127.33, "90th_percentile": 1127.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 421.62, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 421.62, "10th_percentile": 421.62, "90th_percentile": 421.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 882.24, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 882.24, "10th_percentile": 882.24, "90th_percentile": 882.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 882.24, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 882.24, "10th_percentile": 882.24, "90th_percentile": 882.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 432.89, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 432.89, "10th_percentile": 432.89, "90th_percentile": 432.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 432.89, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 432.89, "10th_percentile": 432.89, "90th_percentile": 432.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2254.65, "10th_percentile": 2254.65, "90th_percentile": 2254.65, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2254.65, "10th_percentile": 2254.65, "90th_percentile": 2254.65, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2254.65, "10th_percentile": 2254.65, "90th_percentile": 2254.65, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2254.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2254.65, "10th_percentile": 2254.65, "90th_percentile": 2254.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2254.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2254.65, "10th_percentile": 2254.65, "90th_percentile": 2254.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2254.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2254.65, "10th_percentile": 2254.65, "90th_percentile": 2254.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2254.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2254.65, "10th_percentile": 2254.65, "90th_percentile": 2254.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2254.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2254.65, "10th_percentile": 2254.65, "90th_percentile": 2254.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2254.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2254.65, "10th_percentile": 2254.65, "90th_percentile": 2254.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2254.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2254.65, "10th_percentile": 2254.65, "90th_percentile": 2254.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2254.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2254.65, "10th_percentile": 2254.65, "90th_percentile": 2254.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "AUGMENT TIB 5MM SZEF RT MEDIAL HALF BLOCK PERSONA", "code_information": [ { "code": "SUP-352595", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 360.74, "maximum": 2254.65, "setting": "outpatient", "gross_charge": 2254.65, "discounted_cash": 1578.25, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1152.13, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2248.51, "10th_percentile": 2248.51, "90th_percentile": 2248.51, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 360.74, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 360.74, "10th_percentile": 360.74, "90th_percentile": 360.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 360.74, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 360.74, "10th_percentile": 360.74, "90th_percentile": 360.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 360.74, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 360.74, "10th_percentile": 360.74, "90th_percentile": 360.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2254.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,254.65 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2254.65, "10th_percentile": 2254.65, "90th_percentile": 2254.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,254.65 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 1021.36, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1021.36, "10th_percentile": 1021.36, "90th_percentile": 1021.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1127.33, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1127.33, "10th_percentile": 1127.33, "90th_percentile": 1127.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1352.79, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1352.79, "10th_percentile": 1352.79, "90th_percentile": 1352.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1448.16, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1448.16, "10th_percentile": 1448.16, "90th_percentile": 1448.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1690.99, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1690.99, "10th_percentile": 1690.99, "90th_percentile": 1690.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1578.26, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1578.26, "10th_percentile": 1578.26, "90th_percentile": 1578.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1690.99, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1690.99, "10th_percentile": 1690.99, "90th_percentile": 1690.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2254.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2254.65, "10th_percentile": 2254.65, "90th_percentile": 2254.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 421.62, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 421.62, "10th_percentile": 421.62, "90th_percentile": 421.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 667.38, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 667.38, "10th_percentile": 667.38, "90th_percentile": 667.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1803.72, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1803.72, "10th_percentile": 1803.72, "90th_percentile": 1803.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1127.33, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1127.33, "10th_percentile": 1127.33, "90th_percentile": 1127.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1916.45, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1916.45, "10th_percentile": 1916.45, "90th_percentile": 1916.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 432.89, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 432.89, "10th_percentile": 432.89, "90th_percentile": 432.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1280.64, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1280.64, "10th_percentile": 1280.64, "90th_percentile": 1280.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 882.24, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 882.24, "10th_percentile": 882.24, "90th_percentile": 882.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2254.65, "10th_percentile": 2254.65, "90th_percentile": 2254.65, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2254.65, "10th_percentile": 2254.65, "90th_percentile": 2254.65, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2254.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2254.65, "10th_percentile": 2254.65, "90th_percentile": 2254.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2254.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2254.65, "10th_percentile": 2254.65, "90th_percentile": 2254.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2254.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2254.65, "10th_percentile": 2254.65, "90th_percentile": 2254.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2254.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2254.65, "10th_percentile": 2254.65, "90th_percentile": 2254.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2254.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2254.65, "10th_percentile": 2254.65, "90th_percentile": 2254.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2254.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2254.65, "10th_percentile": 2254.65, "90th_percentile": 2254.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2254.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2254.65, "10th_percentile": 2254.65, "90th_percentile": 2254.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1280.64, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1280.64, "10th_percentile": 1280.64, "90th_percentile": 1280.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 764.33, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 764.33, "10th_percentile": 764.33, "90th_percentile": 764.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 484.75, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 484.75, "10th_percentile": 484.75, "90th_percentile": 484.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1803.72, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1803.72, "10th_percentile": 1803.72, "90th_percentile": 1803.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 882.24, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 882.24, "10th_percentile": 882.24, "90th_percentile": 882.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 432.89, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 432.89, "10th_percentile": 432.89, "90th_percentile": 432.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2254.65, "10th_percentile": 2254.65, "90th_percentile": 2254.65, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2254.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2254.65, "10th_percentile": 2254.65, "90th_percentile": 2254.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "AUGMENT TIB SM TRAB METAL CENTRAL REV PERSONA", "code_information": [ { "code": "SUP-374147", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 1680.74, "maximum": 10504.61, "setting": "outpatient", "gross_charge": 10504.61, "discounted_cash": 7353.23, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 5367.86, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2248.51, "10th_percentile": 2248.51, "90th_percentile": 2248.51, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 1680.74, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1680.74, "10th_percentile": 1680.74, "90th_percentile": 1680.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1680.74, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1680.74, "10th_percentile": 1680.74, "90th_percentile": 1680.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1680.74, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1680.74, "10th_percentile": 1680.74, "90th_percentile": 1680.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 5966.62, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5966.62, "10th_percentile": 5966.62, "90th_percentile": 5966.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 5966.62, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5966.62, "10th_percentile": 5966.62, "90th_percentile": 5966.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 10504.61, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $10,504.61 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 10504.61, "10th_percentile": 10504.61, "90th_percentile": 10504.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $10,504.61 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 3109.36, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3109.36, "10th_percentile": 3109.36, "90th_percentile": 3109.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 10504.61, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 10504.61, "10th_percentile": 10504.61, "90th_percentile": 10504.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 7878.46, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 7878.46, "10th_percentile": 7878.46, "90th_percentile": 7878.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 3561.06, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 3561.06, "10th_percentile": 3561.06, "90th_percentile": 3561.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 8403.69, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8403.69, "10th_percentile": 8403.69, "90th_percentile": 8403.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 7878.46, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 7878.46, "10th_percentile": 7878.46, "90th_percentile": 7878.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 2258.49, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 2258.49, "10th_percentile": 2258.49, "90th_percentile": 2258.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 6747.11, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 6747.11, "10th_percentile": 6747.11, "90th_percentile": 6747.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 5252.31, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5252.31, "10th_percentile": 5252.31, "90th_percentile": 5252.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 8403.69, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 8403.69, "10th_percentile": 8403.69, "90th_percentile": 8403.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 4758.59, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4758.59, "10th_percentile": 4758.59, "90th_percentile": 4758.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 7353.23, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 7353.23, "10th_percentile": 7353.23, "90th_percentile": 7353.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 6302.77, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 6302.77, "10th_percentile": 6302.77, "90th_percentile": 6302.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 8928.92, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 8928.92, "10th_percentile": 8928.92, "90th_percentile": 8928.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 5252.31, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 5252.31, "10th_percentile": 5252.31, "90th_percentile": 5252.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 1964.36, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1964.36, "10th_percentile": 1964.36, "90th_percentile": 1964.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 4110.45, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4110.45, "10th_percentile": 4110.45, "90th_percentile": 4110.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 4110.45, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4110.45, "10th_percentile": 4110.45, "90th_percentile": 4110.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 2016.89, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2016.89, "10th_percentile": 2016.89, "90th_percentile": 2016.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 2016.89, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2016.89, "10th_percentile": 2016.89, "90th_percentile": 2016.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 10504.61, "10th_percentile": 10504.61, "90th_percentile": 10504.61, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 10504.61, "10th_percentile": 10504.61, "90th_percentile": 10504.61, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 10504.61, "10th_percentile": 10504.61, "90th_percentile": 10504.61, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 10504.61, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 10504.61, "10th_percentile": 10504.61, "90th_percentile": 10504.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 10504.61, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 10504.61, "10th_percentile": 10504.61, "90th_percentile": 10504.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 10504.61, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 10504.61, "10th_percentile": 10504.61, "90th_percentile": 10504.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 10504.61, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 10504.61, "10th_percentile": 10504.61, "90th_percentile": 10504.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 10504.61, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 10504.61, "10th_percentile": 10504.61, "90th_percentile": 10504.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 10504.61, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 10504.61, "10th_percentile": 10504.61, "90th_percentile": 10504.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 10504.61, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 10504.61, "10th_percentile": 10504.61, "90th_percentile": 10504.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 10504.61, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 10504.61, "10th_percentile": 10504.61, "90th_percentile": 10504.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "AVANCE NERVE GRAFT 1-2MM X 30MM", "code_information": [ { "code": "SUP-163402", "type": "CDM" }, { "code": "C1762", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 1184.31, "maximum": 7401.91, "setting": "outpatient", "gross_charge": 7401.91, "discounted_cash": 5181.34, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 3782.38, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3782.38, "10th_percentile": 3782.38, "90th_percentile": 3782.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 3353.07, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3353.07, "10th_percentile": 3353.07, "90th_percentile": 3353.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 7401.91, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 7401.91, "10th_percentile": 7401.91, "90th_percentile": 7401.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 7401.91, "10th_percentile": 7401.91, "90th_percentile": 7401.91, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7401.91, "10th_percentile": 7401.91, "90th_percentile": 7401.91, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7401.91, "10th_percentile": 7401.91, "90th_percentile": 7401.91, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 4754.25, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 4754.25, "10th_percentile": 4754.25, "90th_percentile": 4754.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 3700.96, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 3700.96, "10th_percentile": 3700.96, "90th_percentile": 3700.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 6291.62, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 6291.62, "10th_percentile": 6291.62, "90th_percentile": 6291.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 4441.15, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 4441.15, "10th_percentile": 4441.15, "90th_percentile": 4441.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 5181.34, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 5181.34, "10th_percentile": 5181.34, "90th_percentile": 5181.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 1591.41, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 1411.33, "10th_percentile": 1411.33, "90th_percentile": 1411.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 2190.97, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2190.97, "10th_percentile": 2190.97, "90th_percentile": 2190.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 5921.53, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5921.53, "10th_percentile": 5921.53, "90th_percentile": 5921.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 1384.16, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1384.16, "10th_percentile": 1384.16, "90th_percentile": 1384.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 5921.53, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 5921.53, "10th_percentile": 5921.53, "90th_percentile": 5921.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 3700.96, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3700.96, "10th_percentile": 3700.96, "90th_percentile": 3700.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 5551.43, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 5551.43, "10th_percentile": 5551.43, "90th_percentile": 5551.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 5551.43, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 5551.43, "10th_percentile": 5551.43, "90th_percentile": 5551.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 2509.25, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 2509.25, "10th_percentile": 2509.25, "90th_percentile": 2509.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 7401.91, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $7,401.91 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 7401.91, "10th_percentile": 7401.91, "90th_percentile": 7401.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $7,401.91 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2896.37, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2896.37, "10th_percentile": 2896.37, "90th_percentile": 2896.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2896.37, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2896.37, "10th_percentile": 2896.37, "90th_percentile": 2896.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1421.17, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1421.17, "10th_percentile": 1421.17, "90th_percentile": 1421.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1421.17, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1421.17, "10th_percentile": 1421.17, "90th_percentile": 1421.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 4204.28, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4204.28, "10th_percentile": 4204.28, "90th_percentile": 4204.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 4204.28, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4204.28, "10th_percentile": 4204.28, "90th_percentile": 4204.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1184.31, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1184.31, "10th_percentile": 1184.31, "90th_percentile": 1184.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1184.31, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1184.31, "10th_percentile": 1184.31, "90th_percentile": 1184.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 1184.31, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1184.31, "10th_percentile": 1184.31, "90th_percentile": 1184.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7401.91, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7401.91, "10th_percentile": 7401.91, "90th_percentile": 7401.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7401.91, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7401.91, "10th_percentile": 7401.91, "90th_percentile": 7401.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7401.91, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7401.91, "10th_percentile": 7401.91, "90th_percentile": 7401.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7401.91, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7401.91, "10th_percentile": 7401.91, "90th_percentile": 7401.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7401.91, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7401.91, "10th_percentile": 7401.91, "90th_percentile": 7401.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7401.91, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7401.91, "10th_percentile": 7401.91, "90th_percentile": 7401.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7401.91, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7401.91, "10th_percentile": 7401.91, "90th_percentile": 7401.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7401.91, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7401.91, "10th_percentile": 7401.91, "90th_percentile": 7401.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "AXIEM TRACER POINTER / PROBE 9735428 (2 of 2 parts)", "code_information": [ { "code": "SUP-358865", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 190.31, "maximum": 1360.36, "setting": "outpatient", "gross_charge": 1360.36, "discounted_cash": 952.25, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 532.31, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 532.31, "10th_percentile": 532.31, "90th_percentile": 532.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 230.31, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 230.31, "10th_percentile": 230.31, "90th_percentile": 230.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 194.12, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 194.12, "10th_percentile": 194.12, "90th_percentile": 194.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 190.31, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 190.31, "10th_percentile": 190.31, "90th_percentile": 190.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 602.37, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 602.37, "10th_percentile": 602.37, "90th_percentile": 602.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1360.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,360.36 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1360.36, "10th_percentile": 1360.36, "90th_percentile": 1360.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,360.36 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 461.16, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 461.16, "10th_percentile": 461.16, "90th_percentile": 461.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 292.48, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 292.48, "10th_percentile": 292.48, "90th_percentile": 292.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1020.27, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1020.27, "10th_percentile": 1020.27, "90th_percentile": 1020.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1020.27, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1020.27, "10th_percentile": 1020.27, "90th_percentile": 1020.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 532.31, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 532.31, "10th_percentile": 532.31, "90th_percentile": 532.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1156.31, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1156.31, "10th_percentile": 1156.31, "90th_percentile": 1156.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 952.25, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 952.25, "10th_percentile": 952.25, "90th_percentile": 952.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 680.18, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 680.18, "10th_percentile": 680.18, "90th_percentile": 680.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 680.18, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 680.18, "10th_percentile": 680.18, "90th_percentile": 680.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 816.22, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 816.22, "10th_percentile": 816.22, "90th_percentile": 816.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 873.76, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 873.76, "10th_percentile": 873.76, "90th_percentile": 873.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 602.37, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 602.37, "10th_percentile": 602.37, "90th_percentile": 602.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1088.29, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1088.29, "10th_percentile": 1088.29, "90th_percentile": 1088.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 254.39, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 254.39, "10th_percentile": 254.39, "90th_percentile": 254.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 402.67, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 402.67, "10th_percentile": 402.67, "90th_percentile": 402.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1088.29, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1088.29, "10th_percentile": 1088.29, "90th_percentile": 1088.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1360.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1360.36, "10th_percentile": 1360.36, "90th_percentile": 1360.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 616.24, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 616.24, "10th_percentile": 616.24, "90th_percentile": 616.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 695.14, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 695.14, "10th_percentile": 695.14, "90th_percentile": 695.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 772.68, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 772.68, "10th_percentile": 772.68, "90th_percentile": 772.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 772.68, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 772.68, "10th_percentile": 772.68, "90th_percentile": 772.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1360.36, "10th_percentile": 1360.36, "90th_percentile": 1360.36, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1360.36, "10th_percentile": 1360.36, "90th_percentile": 1360.36, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1360.36, "10th_percentile": 1360.36, "90th_percentile": 1360.36, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1360.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1360.36, "10th_percentile": 1360.36, "90th_percentile": 1360.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1360.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1360.36, "10th_percentile": 1360.36, "90th_percentile": 1360.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1360.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1360.36, "10th_percentile": 1360.36, "90th_percentile": 1360.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1360.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1360.36, "10th_percentile": 1360.36, "90th_percentile": 1360.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1360.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1360.36, "10th_percentile": 1360.36, "90th_percentile": 1360.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1360.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1360.36, "10th_percentile": 1360.36, "90th_percentile": 1360.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1360.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1360.36, "10th_percentile": 1360.36, "90th_percentile": 1360.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1360.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1360.36, "10th_percentile": 1360.36, "90th_percentile": 1360.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "AZITHROMYCIN 250 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-20943", "type": "CDM" }, { "code": "J3490", "type": "HCPCS" }, { "code": "0637", "type": "RC" }, { "code": "65862-0641-30", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.76, "maximum": 4.75, "setting": "outpatient", "gross_charge": 4.75, "discounted_cash": 3.32, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4.75, "10th_percentile": 4.75, "90th_percentile": 4.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4.75, "10th_percentile": 4.75, "90th_percentile": 4.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 4.75, "10th_percentile": 4.75, "90th_percentile": 4.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 4.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $4.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 4.75, "10th_percentile": 4.75, "90th_percentile": 4.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $4.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 4.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 4.75, "10th_percentile": 4.75, "90th_percentile": 4.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4.75, "10th_percentile": 4.75, "90th_percentile": 4.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4.75, "10th_percentile": 4.75, "90th_percentile": 4.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4.75, "10th_percentile": 4.75, "90th_percentile": 4.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4.75, "10th_percentile": 4.75, "90th_percentile": 4.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4.75, "10th_percentile": 4.75, "90th_percentile": 4.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4.75, "10th_percentile": 4.75, "90th_percentile": 4.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4.75, "10th_percentile": 4.75, "90th_percentile": 4.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4.75, "10th_percentile": 4.75, "90th_percentile": 4.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 2.7, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.7, "10th_percentile": 2.7, "90th_percentile": 2.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 1.61, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 1.61, "10th_percentile": 1.61, "90th_percentile": 1.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 1.02, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 1.02, "10th_percentile": 1.02, "90th_percentile": 1.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1.86, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.86, "10th_percentile": 1.86, "90th_percentile": 1.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.91, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.91, "10th_percentile": 0.91, "90th_percentile": 0.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 3.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 3.8, "10th_percentile": 3.8, "90th_percentile": 3.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.76, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.76, "10th_percentile": 0.76, "90th_percentile": 0.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.76, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.76, "10th_percentile": 0.76, "90th_percentile": 0.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.76, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.76, "10th_percentile": 0.76, "90th_percentile": 0.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1.86, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.86, "10th_percentile": 1.86, "90th_percentile": 1.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.91, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.91, "10th_percentile": 0.91, "90th_percentile": 0.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 2.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.38, "10th_percentile": 2.38, "90th_percentile": 2.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 3.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.8, "10th_percentile": 3.8, "90th_percentile": 3.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 3.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 3.56, "10th_percentile": 3.56, "90th_percentile": 3.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 2.7, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.7, "10th_percentile": 2.7, "90th_percentile": 2.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 3.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 3.56, "10th_percentile": 3.56, "90th_percentile": 3.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 4.04, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 4.04, "10th_percentile": 4.04, "90th_percentile": 4.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 2.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 2.38, "10th_percentile": 2.38, "90th_percentile": 2.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 2.85, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 2.85, "10th_percentile": 2.85, "90th_percentile": 2.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 3.33, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 3.33, "10th_percentile": 3.33, "90th_percentile": 3.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 3.05, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 3.05, "10th_percentile": 3.05, "90th_percentile": 3.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 2.43, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.43, "10th_percentile": 2.43, "90th_percentile": 2.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 2.15, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.15, "10th_percentile": 2.15, "90th_percentile": 2.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "Adult Oxygen Mask Non-Rebreather 7Ft", "code_information": [ { "code": "SUP-161453", "type": "CDM" }, { "code": "27103350", "type": "LOCAL" }, { "code": "0271", "type": "RC" } ], "standard_charges": [ { "minimum": 0.4, "maximum": 2.88, "setting": "outpatient", "gross_charge": 2.88, "discounted_cash": 2.02, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.88, "10th_percentile": 2.88, "90th_percentile": 2.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.88, "10th_percentile": 2.88, "90th_percentile": 2.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.88, "10th_percentile": 2.88, "90th_percentile": 2.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.88, "10th_percentile": 2.88, "90th_percentile": 2.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.88, "10th_percentile": 2.88, "90th_percentile": 2.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.88, "10th_percentile": 2.88, "90th_percentile": 2.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.88, "10th_percentile": 2.88, "90th_percentile": 2.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.88, "10th_percentile": 2.88, "90th_percentile": 2.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.98, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.98, "10th_percentile": 0.98, "90th_percentile": 0.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.62, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.62, "10th_percentile": 0.62, "90th_percentile": 0.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.54, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.54, "10th_percentile": 0.54, "90th_percentile": 0.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 2.3, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 2.3, "10th_percentile": 2.3, "90th_percentile": 2.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.44, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.44, "10th_percentile": 1.44, "90th_percentile": 1.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 2.02, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 2.02, "10th_percentile": 2.02, "90th_percentile": 2.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.44, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.44, "10th_percentile": 1.44, "90th_percentile": 1.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 2.3, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.3, "10th_percentile": 2.3, "90th_percentile": 2.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 0.85, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.85, "10th_percentile": 0.85, "90th_percentile": 0.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 2.16, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 2.16, "10th_percentile": 2.16, "90th_percentile": 2.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 2.16, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 2.16, "10th_percentile": 2.16, "90th_percentile": 2.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1.85, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1.85, "10th_percentile": 1.85, "90th_percentile": 1.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1.73, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1.73, "10th_percentile": 1.73, "90th_percentile": 1.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 2.45, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 2.45, "10th_percentile": 2.45, "90th_percentile": 2.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1.47, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.47, "10th_percentile": 1.47, "90th_percentile": 1.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 1.3, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.3, "10th_percentile": 1.3, "90th_percentile": 1.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.88, "10th_percentile": 2.88, "90th_percentile": 2.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.88 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.88, "10th_percentile": 2.88, "90th_percentile": 2.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.88 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.41, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.41, "10th_percentile": 0.41, "90th_percentile": 0.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.4, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.4, "10th_percentile": 0.4, "90th_percentile": 0.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.49, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.49, "10th_percentile": 0.49, "90th_percentile": 0.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1.28, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.28, "10th_percentile": 1.28, "90th_percentile": 1.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1.28, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.28, "10th_percentile": 1.28, "90th_percentile": 1.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.64, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.64, "10th_percentile": 1.64, "90th_percentile": 1.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.64, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.64, "10th_percentile": 1.64, "90th_percentile": 1.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1.13, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.13, "10th_percentile": 1.13, "90th_percentile": 1.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1.13, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.13, "10th_percentile": 1.13, "90th_percentile": 1.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.88, "10th_percentile": 2.88, "90th_percentile": 2.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.88, "10th_percentile": 2.88, "90th_percentile": 2.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.88, "10th_percentile": 2.88, "90th_percentile": 2.88, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "Appendectomy", "code_information": [ { "code": "CASE-44950", "type": "LOCAL" }, { "code": "44950", "type": "CPT" }, { "code": "0360", "type": "RC" } ], "standard_charges": [ { "minimum": 5282.0, "maximum": 5868.0, "setting": "outpatient", "gross_charge": 38270.84, "discounted_cash": 26789.59, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.776346419; Using new claim; Scope: All Financial Classes; Cases: 1; APCs; 100% Billed, and; Pricing Extension - NM HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR NWR; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $38,270.85 @ 12.5% = $4,783.86 due to $0.00 Claim Price", "median_amount": 4783.86, "10th_percentile": 4783.86, "90th_percentile": 4783.86, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.776346419; Using new claim; Scope: All Financial Classes; Cases: 1; APCs; 100% Billed, and; Pricing Extension - NM HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR NWR; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $38,270.85 @ 12.5% = $4,783.86 due to $0.00 Claim Price" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.776346419; Using new claim; Scope: All Financial Classes; Cases: 1; APCs; 100% Billed, and; Pricing Extension - NM HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR NWR; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $38,270.85 @ 12.5% = $4,783.86 due to $0.00 Claim Price", "median_amount": 4783.86, "10th_percentile": 4783.86, "90th_percentile": 4783.86, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.776346419; Using new claim; Scope: All Financial Classes; Cases: 1; APCs; 100% Billed, and; Pricing Extension - NM HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR NWR; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $38,270.85 @ 12.5% = $4,783.86 due to $0.00 Claim Price" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_percentage": 42.2, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 16150.3, "10th_percentile": 16150.3, "90th_percentile": 16150.3, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_percentage": 33.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 12973.81, "10th_percentile": 12973.81, "90th_percentile": 12973.81, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_percentage": 21.5, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 8228.25, "10th_percentile": 8228.25, "90th_percentile": 8228.25, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_percentage": 32.2, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 12323.19, "10th_percentile": 12323.19, "90th_percentile": 12323.19, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 30616.68, "10th_percentile": 30616.68, "90th_percentile": 30616.68, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_percentage": 17.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 6620.84, "10th_percentile": 6620.84, "90th_percentile": 6620.84, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_percentage": 17.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 6620.84, "10th_percentile": 6620.84, "90th_percentile": 6620.84, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_percentage": 17.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 6620.84, "10th_percentile": 6620.84, "90th_percentile": 6620.84, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_percentage": 32.2, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 12323.19, "10th_percentile": 12323.19, "90th_percentile": 12323.19, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 19135.46, "10th_percentile": 19135.46, "90th_percentile": 19135.46, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_percentage": 18.7, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 6881.19, "10th_percentile": 6881.19, "90th_percentile": 6881.19, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 30616.68, "10th_percentile": 30616.68, "90th_percentile": 30616.68, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_percentage": 29.6, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 10878.27, "10th_percentile": 10878.27, "90th_percentile": 10878.27, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 28703.16, "10th_percentile": 28703.16, "90th_percentile": 28703.16, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_percentage": 42.2, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 16150.3, "10th_percentile": 16150.3, "90th_percentile": 16150.3, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 28703.16, "10th_percentile": 28703.16, "90th_percentile": 28703.16, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_percentage": 85.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 32530.22, "10th_percentile": 32530.22, "90th_percentile": 32530.22, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 19135.46, "10th_percentile": 19135.46, "90th_percentile": 19135.46, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 22962.51, "10th_percentile": 22962.51, "90th_percentile": 22962.51, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 26789.62, "10th_percentile": 26789.62, "90th_percentile": 26789.62, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_percentage": 64.23, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 24527.12, "10th_percentile": 24527.12, "90th_percentile": 24527.12, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 38270.85, "10th_percentile": 38270.85, "90th_percentile": 38270.85, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 38270.85, "10th_percentile": 38270.85, "90th_percentile": 38270.85, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 38270.85, "10th_percentile": 38270.85, "90th_percentile": 38270.85, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 38270.85, "10th_percentile": 38270.85, "90th_percentile": 38270.85, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 38270.85, "10th_percentile": 38270.85, "90th_percentile": 38270.85, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 38270.85, "10th_percentile": 38270.85, "90th_percentile": 38270.85, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 38270.85, "10th_percentile": 38270.85, "90th_percentile": 38270.85, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 38270.85, "10th_percentile": 38270.85, "90th_percentile": 38270.85, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 38270.85, "10th_percentile": 38270.85, "90th_percentile": 38270.85, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 38270.85, "10th_percentile": 38270.85, "90th_percentile": 38270.85, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_percentage": 39.13, "standard_charge_algorithm": "Additional drugs, labs, and supplies can be included in reimbursement.", "median_amount": 4242.0, "10th_percentile": 4242.0, "90th_percentile": 4242.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_percentage": 39.13, "standard_charge_algorithm": "Additional drugs, labs, and supplies can be included in reimbursement.", "median_amount": 4242.0, "10th_percentile": 4242.0, "90th_percentile": 4242.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 5282.0, "standard_charge_algorithm": "Re-evaluated: HLB.776346419; Using new claim; Scope: All Financial Classes; Cases: 1; OP Surgery Group 4; Case Rate @ $5,282.00, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5307.86, "10th_percentile": 5307.86, "90th_percentile": 5307.86, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 5868.0, "standard_charge_algorithm": "Re-evaluated: HLB.776346419; Using new claim; Scope: All Financial Classes; Cases: 1; OP Surgery Group 4; Case Rate @ $5,868.00, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5893.86, "10th_percentile": 5893.86, "90th_percentile": 5893.86, "count": "1 through 10", "methodology": "case rate" } ] } ] }, { "description": "B COMPLEX AND C 20-FOLIC ACID 1 MG ORAL CAP", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-87637", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "60258-0162-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.89, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.89, "10th_percentile": 0.89, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.28, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.28, "10th_percentile": 0.28, "90th_percentile": 0.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.68, "10th_percentile": 0.68, "90th_percentile": 0.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.43, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.34, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.34, "10th_percentile": 0.34, "90th_percentile": 0.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.89, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.89, "10th_percentile": 0.89, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1.4, "10th_percentile": 1.4, "90th_percentile": 1.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.37, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.37, "10th_percentile": 0.37, "90th_percentile": 0.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1.2, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1.2, "10th_percentile": 1.2, "90th_percentile": 1.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1.7, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1.7, "10th_percentile": 1.7, "90th_percentile": 1.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.29, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.29, "10th_percentile": 0.29, "90th_percentile": 0.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.59, "10th_percentile": 0.59, "90th_percentile": 0.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1.28, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1.28, "10th_percentile": 1.28, "90th_percentile": 1.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 0.91, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.91, "10th_percentile": 0.91, "90th_percentile": 0.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1.02, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.02, "10th_percentile": 1.02, "90th_percentile": 1.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "B3856 SILH XTRAFLO DEVICE 6FX24CM", "code_information": [ { "code": "SUP-414003", "type": "CDM" }, { "code": "C2617", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 56.71, "maximum": 354.46, "setting": "outpatient", "gross_charge": 354.46, "discounted_cash": 248.12, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 354.46, "10th_percentile": 354.46, "90th_percentile": 354.46, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 354.46, "10th_percentile": 354.46, "90th_percentile": 354.46, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 354.46, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $354.46 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 354.46, "10th_percentile": 354.46, "90th_percentile": 354.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $354.46 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 120.16, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 120.16, "10th_percentile": 120.16, "90th_percentile": 120.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 76.21, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 76.21, "10th_percentile": 76.21, "90th_percentile": 76.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 283.57, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 283.57, "10th_percentile": 283.57, "90th_percentile": 283.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 177.23, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 177.23, "10th_percentile": 177.23, "90th_percentile": 177.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 66.28, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 66.28, "10th_percentile": 66.28, "90th_percentile": 66.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 283.57, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 283.57, "10th_percentile": 283.57, "90th_percentile": 283.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 104.92, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 104.92, "10th_percentile": 104.92, "90th_percentile": 104.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 265.85, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 265.85, "10th_percentile": 265.85, "90th_percentile": 265.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 265.85, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 265.85, "10th_percentile": 265.85, "90th_percentile": 265.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 201.33, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 201.33, "10th_percentile": 201.33, "90th_percentile": 201.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 201.33, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 201.33, "10th_percentile": 201.33, "90th_percentile": 201.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 138.7, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 138.7, "10th_percentile": 138.7, "90th_percentile": 138.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 138.7, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 138.7, "10th_percentile": 138.7, "90th_percentile": 138.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 68.06, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 68.06, "10th_percentile": 68.06, "90th_percentile": 68.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 68.06, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 68.06, "10th_percentile": 68.06, "90th_percentile": 68.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 56.71, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 56.71, "10th_percentile": 56.71, "90th_percentile": 56.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 56.71, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 56.71, "10th_percentile": 56.71, "90th_percentile": 56.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 56.71, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 56.71, "10th_percentile": 56.71, "90th_percentile": 56.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 354.46, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 354.46, "10th_percentile": 354.46, "90th_percentile": 354.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 354.46, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 354.46, "10th_percentile": 354.46, "90th_percentile": 354.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 354.46, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 354.46, "10th_percentile": 354.46, "90th_percentile": 354.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 354.46, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 354.46, "10th_percentile": 354.46, "90th_percentile": 354.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 354.46, "10th_percentile": 354.46, "90th_percentile": 354.46, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 301.29, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 301.29, "10th_percentile": 301.29, "90th_percentile": 301.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 177.23, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 177.23, "10th_percentile": 177.23, "90th_percentile": 177.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 212.68, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 212.68, "10th_percentile": 212.68, "90th_percentile": 212.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 248.12, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 248.12, "10th_percentile": 248.12, "90th_percentile": 248.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 227.67, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 227.67, "10th_percentile": 227.67, "90th_percentile": 227.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 181.13, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 181.13, "10th_percentile": 181.13, "90th_percentile": 181.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 160.57, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 160.57, "10th_percentile": 160.57, "90th_percentile": 160.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 354.46, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 354.46, "10th_percentile": 354.46, "90th_percentile": 354.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 354.46, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 354.46, "10th_percentile": 354.46, "90th_percentile": 354.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 354.46, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 354.46, "10th_percentile": 354.46, "90th_percentile": 354.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 354.46, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 354.46, "10th_percentile": 354.46, "90th_percentile": 354.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 354.46, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 354.46, "10th_percentile": 354.46, "90th_percentile": 354.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BACLOFEN 10 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-860", "type": "CDM" }, { "code": "J3490", "type": "HCPCS" }, { "code": "0637", "type": "RC" }, { "code": "63739-0479-10", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.44, "maximum": 2.75, "setting": "outpatient", "gross_charge": 2.75, "discounted_cash": 1.92, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.56, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.56, "10th_percentile": 1.56, "90th_percentile": 1.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.93, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.93, "10th_percentile": 0.93, "90th_percentile": 0.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.59, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.59, "10th_percentile": 0.59, "90th_percentile": 0.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1.08, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.08, "10th_percentile": 1.08, "90th_percentile": 1.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.53, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.53, "10th_percentile": 0.53, "90th_percentile": 0.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 2.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 2.2, "10th_percentile": 2.2, "90th_percentile": 2.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.44, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.44, "10th_percentile": 0.44, "90th_percentile": 0.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.44, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.44, "10th_percentile": 0.44, "90th_percentile": 0.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.44, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.44, "10th_percentile": 0.44, "90th_percentile": 0.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1.08, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.08, "10th_percentile": 1.08, "90th_percentile": 1.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.53, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.53, "10th_percentile": 0.53, "90th_percentile": 0.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.38, "10th_percentile": 1.38, "90th_percentile": 1.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 2.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.2, "10th_percentile": 2.2, "90th_percentile": 2.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 2.06, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 2.06, "10th_percentile": 2.06, "90th_percentile": 2.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.56, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.56, "10th_percentile": 1.56, "90th_percentile": 1.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 2.06, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 2.06, "10th_percentile": 2.06, "90th_percentile": 2.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 2.34, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 2.34, "10th_percentile": 2.34, "90th_percentile": 2.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.38, "10th_percentile": 1.38, "90th_percentile": 1.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1.65, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1.65, "10th_percentile": 1.65, "90th_percentile": 1.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1.93, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1.93, "10th_percentile": 1.93, "90th_percentile": 1.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1.77, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1.77, "10th_percentile": 1.77, "90th_percentile": 1.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1.41, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.41, "10th_percentile": 1.41, "90th_percentile": 1.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 1.25, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.25, "10th_percentile": 1.25, "90th_percentile": 1.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.75, "10th_percentile": 2.75, "90th_percentile": 2.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "BALANCED SALT SOLN NO.1 IRRIG. IO SOLN", "drug_information": { "unit": 500.0, "type": "ML" }, "code_information": [ { "code": "RX-94533", "type": "CDM" }, { "code": "25000000", "type": "LOCAL" }, { "code": "0250", "type": "RC" }, { "code": "00065-0800-94", "type": "NDC" } ], "standard_charges": [ { "minimum": 55.05, "maximum": 393.5, "setting": "outpatient", "gross_charge": 393.5, "discounted_cash": 275.45, "payers_information": [ { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 393.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 393.5, "10th_percentile": 393.5, "90th_percentile": 393.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 393.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 393.5, "10th_percentile": 393.5, "90th_percentile": 393.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 393.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 393.5, "10th_percentile": 393.5, "90th_percentile": 393.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 393.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 393.5, "10th_percentile": 393.5, "90th_percentile": 393.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 393.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 393.5, "10th_percentile": 393.5, "90th_percentile": 393.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 393.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 393.5, "10th_percentile": 393.5, "90th_percentile": 393.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 393.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 393.5, "10th_percentile": 393.5, "90th_percentile": 393.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 393.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $393.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 393.5, "10th_percentile": 393.5, "90th_percentile": 393.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $393.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 174.24, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 174.24, "10th_percentile": 174.24, "90th_percentile": 174.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 55.05, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 55.05, "10th_percentile": 55.05, "90th_percentile": 55.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 56.15, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 56.15, "10th_percentile": 56.15, "90th_percentile": 56.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 153.98, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 153.98, "10th_percentile": 153.98, "90th_percentile": 153.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 223.51, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 223.51, "10th_percentile": 223.51, "90th_percentile": 223.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 196.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 196.75, "10th_percentile": 196.75, "90th_percentile": 196.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 275.45, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 275.45, "10th_percentile": 275.45, "90th_percentile": 275.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 178.26, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 178.26, "10th_percentile": 178.26, "90th_percentile": 178.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 201.08, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 201.08, "10th_percentile": 201.08, "90th_percentile": 201.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 393.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 393.5, "10th_percentile": 393.5, "90th_percentile": 393.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 236.1, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 236.1, "10th_percentile": 236.1, "90th_percentile": 236.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 252.75, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 252.75, "10th_percentile": 252.75, "90th_percentile": 252.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 334.48, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 334.48, "10th_percentile": 334.48, "90th_percentile": 334.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 295.13, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 295.13, "10th_percentile": 295.13, "90th_percentile": 295.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 73.58, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 73.58, "10th_percentile": 73.58, "90th_percentile": 73.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 116.48, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 116.48, "10th_percentile": 116.48, "90th_percentile": 116.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 314.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 314.8, "10th_percentile": 314.8, "90th_percentile": 314.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 295.13, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 295.13, "10th_percentile": 295.13, "90th_percentile": 295.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 196.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 196.75, "10th_percentile": 196.75, "90th_percentile": 196.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 393.5, "10th_percentile": 393.5, "90th_percentile": 393.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 393.5, "10th_percentile": 393.5, "90th_percentile": 393.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 393.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 393.5, "10th_percentile": 393.5, "90th_percentile": 393.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 174.24, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 174.24, "10th_percentile": 174.24, "90th_percentile": 174.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 153.98, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 153.98, "10th_percentile": 153.98, "90th_percentile": 153.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 223.51, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 223.51, "10th_percentile": 223.51, "90th_percentile": 223.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 66.62, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 66.62, "10th_percentile": 66.62, "90th_percentile": 66.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 133.4, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 133.4, "10th_percentile": 133.4, "90th_percentile": 133.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 84.6, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 84.6, "10th_percentile": 84.6, "90th_percentile": 84.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 314.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 314.8, "10th_percentile": 314.8, "90th_percentile": 314.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 393.5, "10th_percentile": 393.5, "90th_percentile": 393.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" } ] } ] }, { "description": "BALLOON ANGIO 5X60MM 135CM 0.035OTW DRG CTD STELLAREX", "code_information": [ { "code": "SUP-420103", "type": "CDM" }, { "code": "C2623", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 479.0, "maximum": 2993.75, "setting": "outpatient", "gross_charge": 2993.75, "discounted_cash": 2095.62, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2993.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2993.75, "10th_percentile": 2993.75, "90th_percentile": 2993.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2993.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2993.75, "10th_percentile": 2993.75, "90th_percentile": 2993.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2993.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2993.75, "10th_percentile": 2993.75, "90th_percentile": 2993.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2993.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2993.75, "10th_percentile": 2993.75, "90th_percentile": 2993.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2993.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2993.75, "10th_percentile": 2993.75, "90th_percentile": 2993.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2993.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2993.75, "10th_percentile": 2993.75, "90th_percentile": 2993.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2993.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2993.75, "10th_percentile": 2993.75, "90th_percentile": 2993.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2993.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2993.75, "10th_percentile": 2993.75, "90th_percentile": 2993.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2993.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,993.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2993.75, "10th_percentile": 2993.75, "90th_percentile": 2993.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,993.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 479.0, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 479.0, "10th_percentile": 479.0, "90th_percentile": 479.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 479.0, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 479.0, "10th_percentile": 479.0, "90th_percentile": 479.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 479.0, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 479.0, "10th_percentile": 479.0, "90th_percentile": 479.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1171.45, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1171.45, "10th_percentile": 1171.45, "90th_percentile": 1171.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 574.8, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 574.8, "10th_percentile": 574.8, "90th_percentile": 574.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1700.45, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1700.45, "10th_percentile": 1700.45, "90th_percentile": 1700.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 1014.88, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 1014.88, "10th_percentile": 1014.88, "90th_percentile": 1014.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 643.66, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 643.66, "10th_percentile": 643.66, "90th_percentile": 643.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1171.45, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1171.45, "10th_percentile": 1171.45, "90th_percentile": 1171.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 574.8, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 574.8, "10th_percentile": 574.8, "90th_percentile": 574.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 2395.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 2395.0, "10th_percentile": 2395.0, "90th_percentile": 2395.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1496.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1496.88, "10th_percentile": 1496.88, "90th_percentile": 1496.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 559.83, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 559.83, "10th_percentile": 559.83, "90th_percentile": 559.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 2395.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2395.0, "10th_percentile": 2395.0, "90th_percentile": 2395.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 886.15, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 886.15, "10th_percentile": 886.15, "90th_percentile": 886.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 2245.31, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 2245.31, "10th_percentile": 2245.31, "90th_percentile": 2245.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1700.45, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1700.45, "10th_percentile": 1700.45, "90th_percentile": 1700.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 2245.31, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 2245.31, "10th_percentile": 2245.31, "90th_percentile": 2245.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 2544.69, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 2544.69, "10th_percentile": 2544.69, "90th_percentile": 2544.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1496.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1496.88, "10th_percentile": 1496.88, "90th_percentile": 1496.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1796.25, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1796.25, "10th_percentile": 1796.25, "90th_percentile": 1796.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 2095.63, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 2095.63, "10th_percentile": 2095.63, "90th_percentile": 2095.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1922.89, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1922.89, "10th_percentile": 1922.89, "90th_percentile": 1922.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1529.81, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1529.81, "10th_percentile": 1529.81, "90th_percentile": 1529.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 1356.17, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1356.17, "10th_percentile": 1356.17, "90th_percentile": 1356.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2993.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2993.75, "10th_percentile": 2993.75, "90th_percentile": 2993.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2993.75, "10th_percentile": 2993.75, "90th_percentile": 2993.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2993.75, "10th_percentile": 2993.75, "90th_percentile": 2993.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2993.75, "10th_percentile": 2993.75, "90th_percentile": 2993.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "BANDAGE FOAM COFLEX LF2 4IN 5YD TAN STERILE", "code_information": [ { "code": "SUP-416682", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 0.88, "maximum": 6.32, "setting": "outpatient", "gross_charge": 6.32, "discounted_cash": 4.42, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2.47, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.47, "10th_percentile": 2.47, "90th_percentile": 2.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.07, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.07, "10th_percentile": 1.07, "90th_percentile": 1.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.9, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.9, "10th_percentile": 0.9, "90th_percentile": 0.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.88, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.88, "10th_percentile": 0.88, "90th_percentile": 0.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 2.8, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.8, "10th_percentile": 2.8, "90th_percentile": 2.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 6.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6.32 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 6.32, "10th_percentile": 6.32, "90th_percentile": 6.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6.32 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 4.74, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 4.74, "10th_percentile": 4.74, "90th_percentile": 4.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 4.74, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 4.74, "10th_percentile": 4.74, "90th_percentile": 4.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2.47, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.47, "10th_percentile": 2.47, "90th_percentile": 2.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 5.37, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 5.37, "10th_percentile": 5.37, "90th_percentile": 5.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 4.42, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 4.42, "10th_percentile": 4.42, "90th_percentile": 4.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 3.16, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 3.16, "10th_percentile": 3.16, "90th_percentile": 3.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 3.16, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.16, "10th_percentile": 3.16, "90th_percentile": 3.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 3.79, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 3.79, "10th_percentile": 3.79, "90th_percentile": 3.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 4.06, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 4.06, "10th_percentile": 4.06, "90th_percentile": 4.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 2.8, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.8, "10th_percentile": 2.8, "90th_percentile": 2.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 5.06, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.06, "10th_percentile": 5.06, "90th_percentile": 5.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 1.18, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.18, "10th_percentile": 1.18, "90th_percentile": 1.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 1.87, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.87, "10th_percentile": 1.87, "90th_percentile": 1.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 5.06, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 5.06, "10th_percentile": 5.06, "90th_percentile": 5.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 6.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 6.32, "10th_percentile": 6.32, "90th_percentile": 6.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 2.86, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.86, "10th_percentile": 2.86, "90th_percentile": 2.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 3.23, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.23, "10th_percentile": 3.23, "90th_percentile": 3.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 3.59, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.59, "10th_percentile": 3.59, "90th_percentile": 3.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 6.32, "10th_percentile": 6.32, "90th_percentile": 6.32, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6.32, "10th_percentile": 6.32, "90th_percentile": 6.32, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6.32, "10th_percentile": 6.32, "90th_percentile": 6.32, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.32, "10th_percentile": 6.32, "90th_percentile": 6.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.32, "10th_percentile": 6.32, "90th_percentile": 6.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.32, "10th_percentile": 6.32, "90th_percentile": 6.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.32, "10th_percentile": 6.32, "90th_percentile": 6.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.32, "10th_percentile": 6.32, "90th_percentile": 6.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.32, "10th_percentile": 6.32, "90th_percentile": 6.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.32, "10th_percentile": 6.32, "90th_percentile": 6.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 2.14, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 2.14, "10th_percentile": 2.14, "90th_percentile": 2.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 1.36, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 1.36, "10th_percentile": 1.36, "90th_percentile": 1.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 3.59, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.59, "10th_percentile": 3.59, "90th_percentile": 3.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.32, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.32, "10th_percentile": 6.32, "90th_percentile": 6.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BASEPLATE COMPONENT AUGMENT REV 110032420", "code_information": [ { "code": "SUP-344619", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 1024.84, "maximum": 6405.25, "setting": "outpatient", "gross_charge": 6405.25, "discounted_cash": 4483.67, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 3273.08, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2248.51, "10th_percentile": 2248.51, "90th_percentile": 2248.51, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 1024.84, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1024.84, "10th_percentile": 1024.84, "90th_percentile": 1024.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1024.84, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1024.84, "10th_percentile": 1024.84, "90th_percentile": 1024.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1024.84, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1024.84, "10th_percentile": 1024.84, "90th_percentile": 1024.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 6405.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,405.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 6405.25, "10th_percentile": 6405.25, "90th_percentile": 6405.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,405.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 1377.13, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 1377.13, "10th_percentile": 1377.13, "90th_percentile": 1377.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 3202.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 3202.63, "10th_percentile": 3202.63, "90th_percentile": 3202.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 4803.94, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 4803.94, "10th_percentile": 4803.94, "90th_percentile": 4803.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 4114.09, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 4114.09, "10th_percentile": 4114.09, "90th_percentile": 4114.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 5124.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 5124.2, "10th_percentile": 5124.2, "90th_percentile": 5124.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 4803.94, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 4803.94, "10th_percentile": 4803.94, "90th_percentile": 4803.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 2171.38, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 2171.38, "10th_percentile": 2171.38, "90th_percentile": 2171.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 2901.58, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2901.58, "10th_percentile": 2901.58, "90th_percentile": 2901.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 3843.15, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 3843.15, "10th_percentile": 3843.15, "90th_percentile": 3843.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 4483.68, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 4483.68, "10th_percentile": 4483.68, "90th_percentile": 4483.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 1895.95, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1895.95, "10th_percentile": 1895.95, "90th_percentile": 1895.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 1197.78, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1197.78, "10th_percentile": 1197.78, "90th_percentile": 1197.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 5444.46, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 5444.46, "10th_percentile": 5444.46, "90th_percentile": 5444.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 6405.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 6405.25, "10th_percentile": 6405.25, "90th_percentile": 6405.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 5124.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5124.2, "10th_percentile": 5124.2, "90th_percentile": 5124.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 3202.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3202.63, "10th_percentile": 3202.63, "90th_percentile": 3202.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1229.81, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1229.81, "10th_percentile": 1229.81, "90th_percentile": 1229.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1229.81, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1229.81, "10th_percentile": 1229.81, "90th_percentile": 1229.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2506.37, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2506.37, "10th_percentile": 2506.37, "90th_percentile": 2506.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2506.37, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2506.37, "10th_percentile": 2506.37, "90th_percentile": 2506.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 3638.18, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3638.18, "10th_percentile": 3638.18, "90th_percentile": 3638.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 3638.18, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3638.18, "10th_percentile": 3638.18, "90th_percentile": 3638.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 6405.25, "10th_percentile": 6405.25, "90th_percentile": 6405.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6405.25, "10th_percentile": 6405.25, "90th_percentile": 6405.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6405.25, "10th_percentile": 6405.25, "90th_percentile": 6405.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6405.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6405.25, "10th_percentile": 6405.25, "90th_percentile": 6405.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6405.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6405.25, "10th_percentile": 6405.25, "90th_percentile": 6405.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6405.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6405.25, "10th_percentile": 6405.25, "90th_percentile": 6405.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6405.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6405.25, "10th_percentile": 6405.25, "90th_percentile": 6405.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6405.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6405.25, "10th_percentile": 6405.25, "90th_percentile": 6405.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6405.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6405.25, "10th_percentile": 6405.25, "90th_percentile": 6405.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6405.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6405.25, "10th_percentile": 6405.25, "90th_percentile": 6405.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6405.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6405.25, "10th_percentile": 6405.25, "90th_percentile": 6405.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BASEPLATE GLEN HYBRD SM 4MM", "code_information": [ { "code": "SUP-134103", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 594.41, "maximum": 3715.05, "setting": "outpatient", "gross_charge": 3715.05, "discounted_cash": 2600.53, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1898.39, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2248.51, "10th_percentile": 2248.51, "90th_percentile": 2248.51, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 594.41, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 594.41, "10th_percentile": 594.41, "90th_percentile": 594.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 594.41, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 594.41, "10th_percentile": 594.41, "90th_percentile": 594.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 594.41, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 594.41, "10th_percentile": 594.41, "90th_percentile": 594.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3715.05, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,715.05 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3715.05, "10th_percentile": 3715.05, "90th_percentile": 3715.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,715.05 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 798.74, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 798.74, "10th_percentile": 798.74, "90th_percentile": 798.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1857.53, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1857.53, "10th_percentile": 1857.53, "90th_percentile": 1857.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 2786.29, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 2786.29, "10th_percentile": 2786.29, "90th_percentile": 2786.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 2386.18, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 2386.18, "10th_percentile": 2386.18, "90th_percentile": 2386.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 2972.04, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 2972.04, "10th_percentile": 2972.04, "90th_percentile": 2972.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 2786.29, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 2786.29, "10th_percentile": 2786.29, "90th_percentile": 2786.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 1259.4, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 1259.4, "10th_percentile": 1259.4, "90th_percentile": 1259.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 1682.92, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1682.92, "10th_percentile": 1682.92, "90th_percentile": 1682.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 2229.03, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 2229.03, "10th_percentile": 2229.03, "90th_percentile": 2229.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 2600.54, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 2600.54, "10th_percentile": 2600.54, "90th_percentile": 2600.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 1099.65, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1099.65, "10th_percentile": 1099.65, "90th_percentile": 1099.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 694.71, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 694.71, "10th_percentile": 694.71, "90th_percentile": 694.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 3157.79, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 3157.79, "10th_percentile": 3157.79, "90th_percentile": 3157.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 3715.05, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 3715.05, "10th_percentile": 3715.05, "90th_percentile": 3715.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 2972.04, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2972.04, "10th_percentile": 2972.04, "90th_percentile": 2972.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1857.53, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1857.53, "10th_percentile": 1857.53, "90th_percentile": 1857.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 713.29, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 713.29, "10th_percentile": 713.29, "90th_percentile": 713.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 713.29, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 713.29, "10th_percentile": 713.29, "90th_percentile": 713.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1453.7, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1453.7, "10th_percentile": 1453.7, "90th_percentile": 1453.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1453.7, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1453.7, "10th_percentile": 1453.7, "90th_percentile": 1453.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 2110.15, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2110.15, "10th_percentile": 2110.15, "90th_percentile": 2110.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 2110.15, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2110.15, "10th_percentile": 2110.15, "90th_percentile": 2110.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 3715.05, "10th_percentile": 3715.05, "90th_percentile": 3715.05, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3715.05, "10th_percentile": 3715.05, "90th_percentile": 3715.05, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3715.05, "10th_percentile": 3715.05, "90th_percentile": 3715.05, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3715.05, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3715.05, "10th_percentile": 3715.05, "90th_percentile": 3715.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3715.05, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3715.05, "10th_percentile": 3715.05, "90th_percentile": 3715.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3715.05, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3715.05, "10th_percentile": 3715.05, "90th_percentile": 3715.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3715.05, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3715.05, "10th_percentile": 3715.05, "90th_percentile": 3715.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3715.05, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3715.05, "10th_percentile": 3715.05, "90th_percentile": 3715.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3715.05, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3715.05, "10th_percentile": 3715.05, "90th_percentile": 3715.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3715.05, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3715.05, "10th_percentile": 3715.05, "90th_percentile": 3715.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3715.05, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3715.05, "10th_percentile": 3715.05, "90th_percentile": 3715.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BASEPLATE GLENOID 30MM CMNTD HYDRO COATED POLY AEQUALIS", "code_information": [ { "code": "SUP-374531", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 442.73, "maximum": 2767.07, "setting": "outpatient", "gross_charge": 2767.07, "discounted_cash": 1936.95, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 938.04, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 938.04, "10th_percentile": 938.04, "90th_percentile": 938.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 594.92, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 594.92, "10th_percentile": 594.92, "90th_percentile": 594.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1571.7, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1571.7, "10th_percentile": 1571.7, "90th_percentile": 1571.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2767.07, "10th_percentile": 2767.07, "90th_percentile": 2767.07, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2767.07, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2767.07, "10th_percentile": 2767.07, "90th_percentile": 2767.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1413.97, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2248.51, "10th_percentile": 2248.51, "90th_percentile": 2248.51, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 442.73, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 442.73, "10th_percentile": 442.73, "90th_percentile": 442.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 442.73, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 442.73, "10th_percentile": 442.73, "90th_percentile": 442.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 442.73, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 442.73, "10th_percentile": 442.73, "90th_percentile": 442.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2767.07, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,767.07 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2767.07, "10th_percentile": 2767.07, "90th_percentile": 2767.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,767.07 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1383.54, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1383.54, "10th_percentile": 1383.54, "90th_percentile": 1383.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 2075.3, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 2075.3, "10th_percentile": 2075.3, "90th_percentile": 2075.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1777.29, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1777.29, "10th_percentile": 1777.29, "90th_percentile": 1777.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 2213.66, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 2213.66, "10th_percentile": 2213.66, "90th_percentile": 2213.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 2075.3, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 2075.3, "10th_percentile": 2075.3, "90th_percentile": 2075.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 1253.48, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1253.48, "10th_percentile": 1253.48, "90th_percentile": 1253.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1660.24, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1660.24, "10th_percentile": 1660.24, "90th_percentile": 1660.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1936.95, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1936.95, "10th_percentile": 1936.95, "90th_percentile": 1936.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 819.05, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 819.05, "10th_percentile": 819.05, "90th_percentile": 819.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 517.44, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 517.44, "10th_percentile": 517.44, "90th_percentile": 517.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 2352.01, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 2352.01, "10th_percentile": 2352.01, "90th_percentile": 2352.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2767.07, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2767.07, "10th_percentile": 2767.07, "90th_percentile": 2767.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 2213.66, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2213.66, "10th_percentile": 2213.66, "90th_percentile": 2213.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1383.54, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1383.54, "10th_percentile": 1383.54, "90th_percentile": 1383.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 531.28, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 531.28, "10th_percentile": 531.28, "90th_percentile": 531.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 531.28, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 531.28, "10th_percentile": 531.28, "90th_percentile": 531.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1082.75, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1082.75, "10th_percentile": 1082.75, "90th_percentile": 1082.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1082.75, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1082.75, "10th_percentile": 1082.75, "90th_percentile": 1082.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1571.7, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1571.7, "10th_percentile": 1571.7, "90th_percentile": 1571.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2767.07, "10th_percentile": 2767.07, "90th_percentile": 2767.07, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2767.07, "10th_percentile": 2767.07, "90th_percentile": 2767.07, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2767.07, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2767.07, "10th_percentile": 2767.07, "90th_percentile": 2767.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2767.07, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2767.07, "10th_percentile": 2767.07, "90th_percentile": 2767.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2767.07, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2767.07, "10th_percentile": 2767.07, "90th_percentile": 2767.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2767.07, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2767.07, "10th_percentile": 2767.07, "90th_percentile": 2767.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2767.07, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2767.07, "10th_percentile": 2767.07, "90th_percentile": 2767.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2767.07, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2767.07, "10th_percentile": 2767.07, "90th_percentile": 2767.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2767.07, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2767.07, "10th_percentile": 2767.07, "90th_percentile": 2767.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BASEPLATE MONOBLCK 24MM POST SHLDR MOD UNIVERS REVERS", "code_information": [ { "code": "SUP-423870", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 799.38, "maximum": 4996.1, "setting": "outpatient", "gross_charge": 4996.1, "discounted_cash": 3497.27, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 799.38, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 799.38, "10th_percentile": 799.38, "90th_percentile": 799.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 799.38, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 799.38, "10th_percentile": 799.38, "90th_percentile": 799.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 799.38, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 799.38, "10th_percentile": 799.38, "90th_percentile": 799.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 4996.1, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $4,996.10 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 4996.1, "10th_percentile": 4996.1, "90th_percentile": 4996.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $4,996.10 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 1693.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 1693.68, "10th_percentile": 1693.68, "90th_percentile": 1693.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 3996.88, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 3996.88, "10th_percentile": 3996.88, "90th_percentile": 3996.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 934.27, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 934.27, "10th_percentile": 934.27, "90th_percentile": 934.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 1074.16, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 1074.16, "10th_percentile": 1074.16, "90th_percentile": 1074.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 2498.05, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2498.05, "10th_percentile": 2498.05, "90th_percentile": 2498.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 959.25, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 959.25, "10th_percentile": 959.25, "90th_percentile": 959.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 959.25, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 959.25, "10th_percentile": 959.25, "90th_percentile": 959.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 2837.78, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2837.78, "10th_percentile": 2837.78, "90th_percentile": 2837.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1954.97, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1954.97, "10th_percentile": 1954.97, "90th_percentile": 1954.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1954.97, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1954.97, "10th_percentile": 1954.97, "90th_percentile": 1954.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4996.1, "10th_percentile": 4996.1, "90th_percentile": 4996.1, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4996.1, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4996.1, "10th_percentile": 4996.1, "90th_percentile": 4996.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 2553.01, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2248.51, "10th_percentile": 2248.51, "90th_percentile": 2248.51, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 2498.05, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 2498.05, "10th_percentile": 2498.05, "90th_percentile": 2498.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 3747.08, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 3747.08, "10th_percentile": 3747.08, "90th_percentile": 3747.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 3209.0, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 3209.0, "10th_percentile": 3209.0, "90th_percentile": 3209.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 3747.08, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 3747.08, "10th_percentile": 3747.08, "90th_percentile": 3747.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 2263.23, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2263.23, "10th_percentile": 2263.23, "90th_percentile": 2263.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 2997.66, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 2997.66, "10th_percentile": 2997.66, "90th_percentile": 2997.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 3497.27, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 3497.27, "10th_percentile": 3497.27, "90th_percentile": 3497.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 1478.85, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1478.85, "10th_percentile": 1478.85, "90th_percentile": 1478.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 4246.69, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 4246.69, "10th_percentile": 4246.69, "90th_percentile": 4246.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 4996.1, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 4996.1, "10th_percentile": 4996.1, "90th_percentile": 4996.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 3996.88, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3996.88, "10th_percentile": 3996.88, "90th_percentile": 3996.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 2837.78, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2837.78, "10th_percentile": 2837.78, "90th_percentile": 2837.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 4996.1, "10th_percentile": 4996.1, "90th_percentile": 4996.1, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4996.1, "10th_percentile": 4996.1, "90th_percentile": 4996.1, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4996.1, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4996.1, "10th_percentile": 4996.1, "90th_percentile": 4996.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4996.1, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4996.1, "10th_percentile": 4996.1, "90th_percentile": 4996.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4996.1, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4996.1, "10th_percentile": 4996.1, "90th_percentile": 4996.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4996.1, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4996.1, "10th_percentile": 4996.1, "90th_percentile": 4996.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4996.1, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4996.1, "10th_percentile": 4996.1, "90th_percentile": 4996.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4996.1, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4996.1, "10th_percentile": 4996.1, "90th_percentile": 4996.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4996.1, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4996.1, "10th_percentile": 4996.1, "90th_percentile": 4996.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BASEPLATE TIB CEM PRI FIX TRITHLON SZ 1", "code_information": [ { "code": "SUP-115137", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 317.7, "maximum": 1985.63, "setting": "outpatient", "gross_charge": 1985.63, "discounted_cash": 1389.94, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1014.66, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2248.51, "10th_percentile": 2248.51, "90th_percentile": 2248.51, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1985.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,985.63 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1985.63, "10th_percentile": 1985.63, "90th_percentile": 1985.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,985.63 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 899.49, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 899.49, "10th_percentile": 899.49, "90th_percentile": 899.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 992.82, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 992.82, "10th_percentile": 992.82, "90th_percentile": 992.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1191.38, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1191.38, "10th_percentile": 1191.38, "90th_percentile": 1191.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1275.37, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1275.37, "10th_percentile": 1275.37, "90th_percentile": 1275.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1489.22, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1489.22, "10th_percentile": 1489.22, "90th_percentile": 1489.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1389.94, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1389.94, "10th_percentile": 1389.94, "90th_percentile": 1389.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1489.22, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1489.22, "10th_percentile": 1489.22, "90th_percentile": 1489.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1985.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1985.63, "10th_percentile": 1985.63, "90th_percentile": 1985.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 371.31, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 371.31, "10th_percentile": 371.31, "90th_percentile": 371.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 587.75, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 587.75, "10th_percentile": 587.75, "90th_percentile": 587.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1588.5, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1588.5, "10th_percentile": 1588.5, "90th_percentile": 1588.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 992.82, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 992.82, "10th_percentile": 992.82, "90th_percentile": 992.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1687.79, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1687.79, "10th_percentile": 1687.79, "90th_percentile": 1687.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 381.24, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 381.24, "10th_percentile": 381.24, "90th_percentile": 381.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1127.84, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1127.84, "10th_percentile": 1127.84, "90th_percentile": 1127.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1985.63, "10th_percentile": 1985.63, "90th_percentile": 1985.63, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1985.63, "10th_percentile": 1985.63, "90th_percentile": 1985.63, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1985.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1985.63, "10th_percentile": 1985.63, "90th_percentile": 1985.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1985.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1985.63, "10th_percentile": 1985.63, "90th_percentile": 1985.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1985.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1985.63, "10th_percentile": 1985.63, "90th_percentile": 1985.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1985.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1985.63, "10th_percentile": 1985.63, "90th_percentile": 1985.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1985.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1985.63, "10th_percentile": 1985.63, "90th_percentile": 1985.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1985.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1985.63, "10th_percentile": 1985.63, "90th_percentile": 1985.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1985.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1985.63, "10th_percentile": 1985.63, "90th_percentile": 1985.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 317.7, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 317.7, "10th_percentile": 317.7, "90th_percentile": 317.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 317.7, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 317.7, "10th_percentile": 317.7, "90th_percentile": 317.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 317.7, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 317.7, "10th_percentile": 317.7, "90th_percentile": 317.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 426.91, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 426.91, "10th_percentile": 426.91, "90th_percentile": 426.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1588.5, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1588.5, "10th_percentile": 1588.5, "90th_percentile": 1588.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 673.13, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 673.13, "10th_percentile": 673.13, "90th_percentile": 673.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 381.24, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 381.24, "10th_percentile": 381.24, "90th_percentile": 381.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 776.98, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 776.98, "10th_percentile": 776.98, "90th_percentile": 776.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 776.98, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 776.98, "10th_percentile": 776.98, "90th_percentile": 776.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1127.84, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1127.84, "10th_percentile": 1127.84, "90th_percentile": 1127.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1985.63, "10th_percentile": 1985.63, "90th_percentile": 1985.63, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1985.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1985.63, "10th_percentile": 1985.63, "90th_percentile": 1985.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BASEPLATE TIB FIN EMPOWR SZ 8 R NON POR", "code_information": [ { "code": "SUP-336703", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 629.56, "maximum": 3934.77, "setting": "outpatient", "gross_charge": 3934.77, "discounted_cash": 2754.34, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 2010.67, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2248.51, "10th_percentile": 2248.51, "90th_percentile": 2248.51, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 629.56, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 629.56, "10th_percentile": 629.56, "90th_percentile": 629.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 629.56, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 629.56, "10th_percentile": 629.56, "90th_percentile": 629.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 629.56, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 629.56, "10th_percentile": 629.56, "90th_percentile": 629.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3934.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,934.77 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3934.77, "10th_percentile": 3934.77, "90th_percentile": 3934.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,934.77 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 845.98, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 845.98, "10th_percentile": 845.98, "90th_percentile": 845.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1967.39, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1967.39, "10th_percentile": 1967.39, "90th_percentile": 1967.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 2951.08, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 2951.08, "10th_percentile": 2951.08, "90th_percentile": 2951.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 2527.3, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 2527.3, "10th_percentile": 2527.3, "90th_percentile": 2527.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 3147.82, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 3147.82, "10th_percentile": 3147.82, "90th_percentile": 3147.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 2951.08, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 2951.08, "10th_percentile": 2951.08, "90th_percentile": 2951.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 1333.89, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 1333.89, "10th_percentile": 1333.89, "90th_percentile": 1333.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 1782.45, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1782.45, "10th_percentile": 1782.45, "90th_percentile": 1782.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 2360.86, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 2360.86, "10th_percentile": 2360.86, "90th_percentile": 2360.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 2754.34, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 2754.34, "10th_percentile": 2754.34, "90th_percentile": 2754.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 1164.69, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1164.69, "10th_percentile": 1164.69, "90th_percentile": 1164.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 735.8, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 735.8, "10th_percentile": 735.8, "90th_percentile": 735.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 3344.55, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 3344.55, "10th_percentile": 3344.55, "90th_percentile": 3344.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 3934.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 3934.77, "10th_percentile": 3934.77, "90th_percentile": 3934.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 3147.82, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3147.82, "10th_percentile": 3147.82, "90th_percentile": 3147.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1967.39, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1967.39, "10th_percentile": 1967.39, "90th_percentile": 1967.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 755.48, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 755.48, "10th_percentile": 755.48, "90th_percentile": 755.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 755.48, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 755.48, "10th_percentile": 755.48, "90th_percentile": 755.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1539.68, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1539.68, "10th_percentile": 1539.68, "90th_percentile": 1539.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1539.68, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1539.68, "10th_percentile": 1539.68, "90th_percentile": 1539.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 2234.95, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2234.95, "10th_percentile": 2234.95, "90th_percentile": 2234.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 2234.95, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2234.95, "10th_percentile": 2234.95, "90th_percentile": 2234.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 3934.77, "10th_percentile": 3934.77, "90th_percentile": 3934.77, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3934.77, "10th_percentile": 3934.77, "90th_percentile": 3934.77, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3934.77, "10th_percentile": 3934.77, "90th_percentile": 3934.77, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3934.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3934.77, "10th_percentile": 3934.77, "90th_percentile": 3934.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3934.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3934.77, "10th_percentile": 3934.77, "90th_percentile": 3934.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3934.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3934.77, "10th_percentile": 3934.77, "90th_percentile": 3934.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3934.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3934.77, "10th_percentile": 3934.77, "90th_percentile": 3934.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3934.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3934.77, "10th_percentile": 3934.77, "90th_percentile": 3934.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3934.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3934.77, "10th_percentile": 3934.77, "90th_percentile": 3934.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3934.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3934.77, "10th_percentile": 3934.77, "90th_percentile": 3934.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3934.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3934.77, "10th_percentile": 3934.77, "90th_percentile": 3934.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BASEPLATE TIB MOB BEAR CEM SZ 5", "code_information": [ { "code": "SUP-20748", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 358.69, "maximum": 2241.84, "setting": "outpatient", "gross_charge": 2241.84, "discounted_cash": 1569.29, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1145.58, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2248.51, "10th_percentile": 2248.51, "90th_percentile": 2248.51, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1439.93, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1439.93, "10th_percentile": 1439.93, "90th_percentile": 1439.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 1015.55, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1015.55, "10th_percentile": 1015.55, "90th_percentile": 1015.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1569.29, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1569.29, "10th_percentile": 1569.29, "90th_percentile": 1569.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2241.84, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2241.84, "10th_percentile": 2241.84, "90th_percentile": 2241.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2241.84, "10th_percentile": 2241.84, "90th_percentile": 2241.84, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2241.84, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2241.84, "10th_percentile": 2241.84, "90th_percentile": 2241.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2241.84, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2241.84, "10th_percentile": 2241.84, "90th_percentile": 2241.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 358.69, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 358.69, "10th_percentile": 358.69, "90th_percentile": 358.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 358.69, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 358.69, "10th_percentile": 358.69, "90th_percentile": 358.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 358.69, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 358.69, "10th_percentile": 358.69, "90th_percentile": 358.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2241.84, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,241.84 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2241.84, "10th_percentile": 2241.84, "90th_percentile": 2241.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,241.84 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1120.92, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1120.92, "10th_percentile": 1120.92, "90th_percentile": 1120.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1345.1, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1345.1, "10th_percentile": 1345.1, "90th_percentile": 1345.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1681.38, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1681.38, "10th_percentile": 1681.38, "90th_percentile": 1681.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 759.98, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 759.98, "10th_percentile": 759.98, "90th_percentile": 759.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1681.38, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1681.38, "10th_percentile": 1681.38, "90th_percentile": 1681.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1793.47, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1793.47, "10th_percentile": 1793.47, "90th_percentile": 1793.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 419.22, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 419.22, "10th_percentile": 419.22, "90th_percentile": 419.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 663.58, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 663.58, "10th_percentile": 663.58, "90th_percentile": 663.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1793.47, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1793.47, "10th_percentile": 1793.47, "90th_percentile": 1793.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 482.0, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 482.0, "10th_percentile": 482.0, "90th_percentile": 482.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1120.92, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1120.92, "10th_percentile": 1120.92, "90th_percentile": 1120.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1905.56, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1905.56, "10th_percentile": 1905.56, "90th_percentile": 1905.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 430.43, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 430.43, "10th_percentile": 430.43, "90th_percentile": 430.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 430.43, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 430.43, "10th_percentile": 430.43, "90th_percentile": 430.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1273.37, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1273.37, "10th_percentile": 1273.37, "90th_percentile": 1273.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1273.37, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1273.37, "10th_percentile": 1273.37, "90th_percentile": 1273.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 877.23, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 877.23, "10th_percentile": 877.23, "90th_percentile": 877.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 877.23, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 877.23, "10th_percentile": 877.23, "90th_percentile": 877.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2241.84, "10th_percentile": 2241.84, "90th_percentile": 2241.84, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2241.84, "10th_percentile": 2241.84, "90th_percentile": 2241.84, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2241.84, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2241.84, "10th_percentile": 2241.84, "90th_percentile": 2241.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2241.84, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2241.84, "10th_percentile": 2241.84, "90th_percentile": 2241.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2241.84, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2241.84, "10th_percentile": 2241.84, "90th_percentile": 2241.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2241.84, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2241.84, "10th_percentile": 2241.84, "90th_percentile": 2241.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2241.84, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2241.84, "10th_percentile": 2241.84, "90th_percentile": 2241.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2241.84, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2241.84, "10th_percentile": 2241.84, "90th_percentile": 2241.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BASEPLATE TIB REV LEGN SZ 5 L", "code_information": [ { "code": "SUP-132062", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 1020.13, "maximum": 6375.79, "setting": "outpatient", "gross_charge": 6375.79, "discounted_cash": 4463.05, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 3258.03, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2248.51, "10th_percentile": 2248.51, "90th_percentile": 2248.51, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 1020.13, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1020.13, "10th_percentile": 1020.13, "90th_percentile": 1020.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1020.13, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1020.13, "10th_percentile": 1020.13, "90th_percentile": 1020.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1020.13, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1020.13, "10th_percentile": 1020.13, "90th_percentile": 1020.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 3621.45, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3621.45, "10th_percentile": 3621.45, "90th_percentile": 3621.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 3621.45, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3621.45, "10th_percentile": 3621.45, "90th_percentile": 3621.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 6375.79, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,375.79 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 6375.79, "10th_percentile": 6375.79, "90th_percentile": 6375.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,375.79 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 1887.23, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1887.23, "10th_percentile": 1887.23, "90th_percentile": 1887.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 6375.79, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 6375.79, "10th_percentile": 6375.79, "90th_percentile": 6375.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 4781.84, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 4781.84, "10th_percentile": 4781.84, "90th_percentile": 4781.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 2161.39, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 2161.39, "10th_percentile": 2161.39, "90th_percentile": 2161.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 5100.63, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5100.63, "10th_percentile": 5100.63, "90th_percentile": 5100.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 4781.84, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 4781.84, "10th_percentile": 4781.84, "90th_percentile": 4781.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 1370.79, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 1370.79, "10th_percentile": 1370.79, "90th_percentile": 1370.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 4095.17, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 4095.17, "10th_percentile": 4095.17, "90th_percentile": 4095.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 3187.9, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3187.9, "10th_percentile": 3187.9, "90th_percentile": 3187.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 5100.63, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 5100.63, "10th_percentile": 5100.63, "90th_percentile": 5100.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 2888.23, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2888.23, "10th_percentile": 2888.23, "90th_percentile": 2888.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 4463.05, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 4463.05, "10th_percentile": 4463.05, "90th_percentile": 4463.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 3825.47, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 3825.47, "10th_percentile": 3825.47, "90th_percentile": 3825.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 5419.42, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 5419.42, "10th_percentile": 5419.42, "90th_percentile": 5419.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 3187.9, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 3187.9, "10th_percentile": 3187.9, "90th_percentile": 3187.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 1192.27, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1192.27, "10th_percentile": 1192.27, "90th_percentile": 1192.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2494.85, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2494.85, "10th_percentile": 2494.85, "90th_percentile": 2494.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2494.85, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2494.85, "10th_percentile": 2494.85, "90th_percentile": 2494.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1224.15, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1224.15, "10th_percentile": 1224.15, "90th_percentile": 1224.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1224.15, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1224.15, "10th_percentile": 1224.15, "90th_percentile": 1224.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 6375.79, "10th_percentile": 6375.79, "90th_percentile": 6375.79, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6375.79, "10th_percentile": 6375.79, "90th_percentile": 6375.79, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6375.79, "10th_percentile": 6375.79, "90th_percentile": 6375.79, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6375.79, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6375.79, "10th_percentile": 6375.79, "90th_percentile": 6375.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6375.79, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6375.79, "10th_percentile": 6375.79, "90th_percentile": 6375.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6375.79, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6375.79, "10th_percentile": 6375.79, "90th_percentile": 6375.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6375.79, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6375.79, "10th_percentile": 6375.79, "90th_percentile": 6375.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6375.79, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6375.79, "10th_percentile": 6375.79, "90th_percentile": 6375.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6375.79, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6375.79, "10th_percentile": 6375.79, "90th_percentile": 6375.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6375.79, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6375.79, "10th_percentile": 6375.79, "90th_percentile": 6375.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6375.79, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6375.79, "10th_percentile": 6375.79, "90th_percentile": 6375.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BASEPLATE TIB STEM CEM PERSONA SZ D 5DEG R", "code_information": [ { "code": "SUP-146058", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 245.96, "maximum": 1537.26, "setting": "outpatient", "gross_charge": 1537.26, "discounted_cash": 1076.08, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 785.54, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2248.51, "10th_percentile": 2248.51, "90th_percentile": 2248.51, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 245.96, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 245.96, "10th_percentile": 245.96, "90th_percentile": 245.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 245.96, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 245.96, "10th_percentile": 245.96, "90th_percentile": 245.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 245.96, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 245.96, "10th_percentile": 245.96, "90th_percentile": 245.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,537.26 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,537.26 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 696.38, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 696.38, "10th_percentile": 696.38, "90th_percentile": 696.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 768.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 768.63, "10th_percentile": 768.63, "90th_percentile": 768.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 922.36, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 922.36, "10th_percentile": 922.36, "90th_percentile": 922.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 987.38, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 987.38, "10th_percentile": 987.38, "90th_percentile": 987.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1152.95, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1152.95, "10th_percentile": 1152.95, "90th_percentile": 1152.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 521.13, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 521.13, "10th_percentile": 521.13, "90th_percentile": 521.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1076.08, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1076.08, "10th_percentile": 1076.08, "90th_percentile": 1076.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1152.95, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1152.95, "10th_percentile": 1152.95, "90th_percentile": 1152.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1229.81, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1229.81, "10th_percentile": 1229.81, "90th_percentile": 1229.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 287.47, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 287.47, "10th_percentile": 287.47, "90th_percentile": 287.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 455.03, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 455.03, "10th_percentile": 455.03, "90th_percentile": 455.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1229.81, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1229.81, "10th_percentile": 1229.81, "90th_percentile": 1229.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 330.51, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 330.51, "10th_percentile": 330.51, "90th_percentile": 330.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 768.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 768.63, "10th_percentile": 768.63, "90th_percentile": 768.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1306.67, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1306.67, "10th_percentile": 1306.67, "90th_percentile": 1306.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 295.15, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 295.15, "10th_percentile": 295.15, "90th_percentile": 295.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 295.15, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 295.15, "10th_percentile": 295.15, "90th_percentile": 295.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 873.16, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 873.16, "10th_percentile": 873.16, "90th_percentile": 873.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 873.16, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 873.16, "10th_percentile": 873.16, "90th_percentile": 873.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 601.53, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 601.53, "10th_percentile": 601.53, "90th_percentile": 601.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 601.53, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 601.53, "10th_percentile": 601.53, "90th_percentile": 601.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BASEPLATE TIB STEM CEM PERSONA SZ H 5DEG L", "code_information": [ { "code": "SUP-147637", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 245.96, "maximum": 1537.26, "setting": "outpatient", "gross_charge": 1537.26, "discounted_cash": 1076.08, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 785.54, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2248.51, "10th_percentile": 2248.51, "90th_percentile": 2248.51, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 245.96, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 245.96, "10th_percentile": 245.96, "90th_percentile": 245.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 245.96, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 245.96, "10th_percentile": 245.96, "90th_percentile": 245.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 245.96, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 245.96, "10th_percentile": 245.96, "90th_percentile": 245.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,537.26 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,537.26 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 330.51, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 330.51, "10th_percentile": 330.51, "90th_percentile": 330.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 768.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 768.63, "10th_percentile": 768.63, "90th_percentile": 768.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1152.95, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1152.95, "10th_percentile": 1152.95, "90th_percentile": 1152.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 987.38, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 987.38, "10th_percentile": 987.38, "90th_percentile": 987.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1229.81, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1229.81, "10th_percentile": 1229.81, "90th_percentile": 1229.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1152.95, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1152.95, "10th_percentile": 1152.95, "90th_percentile": 1152.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 521.13, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 521.13, "10th_percentile": 521.13, "90th_percentile": 521.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 696.38, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 696.38, "10th_percentile": 696.38, "90th_percentile": 696.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 922.36, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 922.36, "10th_percentile": 922.36, "90th_percentile": 922.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1076.08, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1076.08, "10th_percentile": 1076.08, "90th_percentile": 1076.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 455.03, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 455.03, "10th_percentile": 455.03, "90th_percentile": 455.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 287.47, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 287.47, "10th_percentile": 287.47, "90th_percentile": 287.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1306.67, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1306.67, "10th_percentile": 1306.67, "90th_percentile": 1306.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1229.81, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1229.81, "10th_percentile": 1229.81, "90th_percentile": 1229.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 768.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 768.63, "10th_percentile": 768.63, "90th_percentile": 768.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 295.15, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 295.15, "10th_percentile": 295.15, "90th_percentile": 295.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 295.15, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 295.15, "10th_percentile": 295.15, "90th_percentile": 295.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 601.53, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 601.53, "10th_percentile": 601.53, "90th_percentile": 601.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 601.53, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 601.53, "10th_percentile": 601.53, "90th_percentile": 601.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 873.16, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 873.16, "10th_percentile": 873.16, "90th_percentile": 873.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 873.16, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 873.16, "10th_percentile": 873.16, "90th_percentile": 873.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BASEPLATE TIB STEM CEM PERSONA SZ H 5DEG R", "code_information": [ { "code": "SUP-147638", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 245.96, "maximum": 1537.26, "setting": "outpatient", "gross_charge": 1537.26, "discounted_cash": 1076.08, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 785.54, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2248.51, "10th_percentile": 2248.51, "90th_percentile": 2248.51, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 245.96, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 245.96, "10th_percentile": 245.96, "90th_percentile": 245.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 245.96, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 245.96, "10th_percentile": 245.96, "90th_percentile": 245.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 245.96, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 245.96, "10th_percentile": 245.96, "90th_percentile": 245.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,537.26 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,537.26 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 330.51, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 330.51, "10th_percentile": 330.51, "90th_percentile": 330.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 768.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 768.63, "10th_percentile": 768.63, "90th_percentile": 768.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1152.95, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1152.95, "10th_percentile": 1152.95, "90th_percentile": 1152.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 987.38, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 987.38, "10th_percentile": 987.38, "90th_percentile": 987.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1229.81, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1229.81, "10th_percentile": 1229.81, "90th_percentile": 1229.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1152.95, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1152.95, "10th_percentile": 1152.95, "90th_percentile": 1152.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 521.13, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 521.13, "10th_percentile": 521.13, "90th_percentile": 521.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 696.38, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 696.38, "10th_percentile": 696.38, "90th_percentile": 696.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 922.36, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 922.36, "10th_percentile": 922.36, "90th_percentile": 922.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1076.08, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1076.08, "10th_percentile": 1076.08, "90th_percentile": 1076.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 455.03, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 455.03, "10th_percentile": 455.03, "90th_percentile": 455.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 287.47, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 287.47, "10th_percentile": 287.47, "90th_percentile": 287.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1306.67, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1306.67, "10th_percentile": 1306.67, "90th_percentile": 1306.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1229.81, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1229.81, "10th_percentile": 1229.81, "90th_percentile": 1229.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 768.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 768.63, "10th_percentile": 768.63, "90th_percentile": 768.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 295.15, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 295.15, "10th_percentile": 295.15, "90th_percentile": 295.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 295.15, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 295.15, "10th_percentile": 295.15, "90th_percentile": 295.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 601.53, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 601.53, "10th_percentile": 601.53, "90th_percentile": 601.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 601.53, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 601.53, "10th_percentile": 601.53, "90th_percentile": 601.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 873.16, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 873.16, "10th_percentile": 873.16, "90th_percentile": 873.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 873.16, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 873.16, "10th_percentile": 873.16, "90th_percentile": 873.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BASEPLATE TIBIA KNEE EMPOWR L SZ 8", "code_information": [ { "code": "SUP-340453", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 629.56, "maximum": 3934.77, "setting": "outpatient", "gross_charge": 3934.77, "discounted_cash": 2754.34, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 2010.67, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2248.51, "10th_percentile": 2248.51, "90th_percentile": 2248.51, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 629.56, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 629.56, "10th_percentile": 629.56, "90th_percentile": 629.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 629.56, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 629.56, "10th_percentile": 629.56, "90th_percentile": 629.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 629.56, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 629.56, "10th_percentile": 629.56, "90th_percentile": 629.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 2234.95, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2234.95, "10th_percentile": 2234.95, "90th_percentile": 2234.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 2234.95, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2234.95, "10th_percentile": 2234.95, "90th_percentile": 2234.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3934.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,934.77 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3934.77, "10th_percentile": 3934.77, "90th_percentile": 3934.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3,934.77 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 1164.69, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1164.69, "10th_percentile": 1164.69, "90th_percentile": 1164.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 3934.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 3934.77, "10th_percentile": 3934.77, "90th_percentile": 3934.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 2951.08, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 2951.08, "10th_percentile": 2951.08, "90th_percentile": 2951.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 1333.89, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 1333.89, "10th_percentile": 1333.89, "90th_percentile": 1333.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 3147.82, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3147.82, "10th_percentile": 3147.82, "90th_percentile": 3147.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 2951.08, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 2951.08, "10th_percentile": 2951.08, "90th_percentile": 2951.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 845.98, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 845.98, "10th_percentile": 845.98, "90th_percentile": 845.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 2527.3, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 2527.3, "10th_percentile": 2527.3, "90th_percentile": 2527.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1967.39, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1967.39, "10th_percentile": 1967.39, "90th_percentile": 1967.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 3147.82, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 3147.82, "10th_percentile": 3147.82, "90th_percentile": 3147.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 1782.45, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1782.45, "10th_percentile": 1782.45, "90th_percentile": 1782.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 2754.34, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 2754.34, "10th_percentile": 2754.34, "90th_percentile": 2754.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 2360.86, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 2360.86, "10th_percentile": 2360.86, "90th_percentile": 2360.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 3344.55, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 3344.55, "10th_percentile": 3344.55, "90th_percentile": 3344.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1967.39, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1967.39, "10th_percentile": 1967.39, "90th_percentile": 1967.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 735.8, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 735.8, "10th_percentile": 735.8, "90th_percentile": 735.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1539.68, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1539.68, "10th_percentile": 1539.68, "90th_percentile": 1539.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1539.68, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1539.68, "10th_percentile": 1539.68, "90th_percentile": 1539.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 755.48, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 755.48, "10th_percentile": 755.48, "90th_percentile": 755.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 755.48, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 755.48, "10th_percentile": 755.48, "90th_percentile": 755.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 3934.77, "10th_percentile": 3934.77, "90th_percentile": 3934.77, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3934.77, "10th_percentile": 3934.77, "90th_percentile": 3934.77, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3934.77, "10th_percentile": 3934.77, "90th_percentile": 3934.77, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3934.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3934.77, "10th_percentile": 3934.77, "90th_percentile": 3934.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3934.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3934.77, "10th_percentile": 3934.77, "90th_percentile": 3934.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3934.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3934.77, "10th_percentile": 3934.77, "90th_percentile": 3934.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3934.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3934.77, "10th_percentile": 3934.77, "90th_percentile": 3934.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3934.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3934.77, "10th_percentile": 3934.77, "90th_percentile": 3934.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3934.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3934.77, "10th_percentile": 3934.77, "90th_percentile": 3934.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3934.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3934.77, "10th_percentile": 3934.77, "90th_percentile": 3934.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3934.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3934.77, "10th_percentile": 3934.77, "90th_percentile": 3934.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BASKET ZERO TIP NITINOL STONE RETRIEVAL 1.9FR M0063901050", "code_information": [ { "code": "SUP-104215", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 65.29, "maximum": 466.71, "setting": "outpatient", "gross_charge": 466.71, "discounted_cash": 326.7, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 79.01, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 79.01, "10th_percentile": 79.01, "90th_percentile": 79.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 206.66, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 206.66, "10th_percentile": 206.66, "90th_percentile": 206.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 182.62, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 182.62, "10th_percentile": 182.62, "90th_percentile": 182.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 66.6, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 66.6, "10th_percentile": 66.6, "90th_percentile": 66.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 65.29, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 65.29, "10th_percentile": 65.29, "90th_percentile": 65.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 466.71, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $466.71 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 466.71, "10th_percentile": 466.71, "90th_percentile": 466.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $466.71 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 396.7, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 396.7, "10th_percentile": 396.7, "90th_percentile": 396.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 299.77, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 299.77, "10th_percentile": 299.77, "90th_percentile": 299.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 233.36, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 233.36, "10th_percentile": 233.36, "90th_percentile": 233.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 158.21, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 158.21, "10th_percentile": 158.21, "90th_percentile": 158.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 326.7, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 326.7, "10th_percentile": 326.7, "90th_percentile": 326.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 350.03, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 350.03, "10th_percentile": 350.03, "90th_percentile": 350.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 206.66, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 206.66, "10th_percentile": 206.66, "90th_percentile": 206.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 233.36, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 233.36, "10th_percentile": 233.36, "90th_percentile": 233.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 373.37, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 373.37, "10th_percentile": 373.37, "90th_percentile": 373.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 280.03, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 280.03, "10th_percentile": 280.03, "90th_percentile": 280.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 100.34, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 100.34, "10th_percentile": 100.34, "90th_percentile": 100.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 182.62, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 182.62, "10th_percentile": 182.62, "90th_percentile": 182.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 350.03, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 350.03, "10th_percentile": 350.03, "90th_percentile": 350.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 138.15, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 138.15, "10th_percentile": 138.15, "90th_percentile": 138.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 87.27, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 87.27, "10th_percentile": 87.27, "90th_percentile": 87.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 373.37, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 373.37, "10th_percentile": 373.37, "90th_percentile": 373.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 466.71, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 466.71, "10th_percentile": 466.71, "90th_percentile": 466.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 211.42, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 211.42, "10th_percentile": 211.42, "90th_percentile": 211.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 238.49, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 238.49, "10th_percentile": 238.49, "90th_percentile": 238.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 265.09, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 265.09, "10th_percentile": 265.09, "90th_percentile": 265.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 265.09, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 265.09, "10th_percentile": 265.09, "90th_percentile": 265.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 466.71, "10th_percentile": 466.71, "90th_percentile": 466.71, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 466.71, "10th_percentile": 466.71, "90th_percentile": 466.71, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 466.71, "10th_percentile": 466.71, "90th_percentile": 466.71, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 466.71, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 466.71, "10th_percentile": 466.71, "90th_percentile": 466.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 466.71, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 466.71, "10th_percentile": 466.71, "90th_percentile": 466.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 466.71, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 466.71, "10th_percentile": 466.71, "90th_percentile": 466.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 466.71, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 466.71, "10th_percentile": 466.71, "90th_percentile": 466.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 466.71, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 466.71, "10th_percentile": 466.71, "90th_percentile": 466.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 466.71, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 466.71, "10th_percentile": 466.71, "90th_percentile": 466.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 466.71, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 466.71, "10th_percentile": 466.71, "90th_percentile": 466.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 466.71, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 466.71, "10th_percentile": 466.71, "90th_percentile": 466.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BEARING HUMERAL 40MM STD PRLNG 110031421", "code_information": [ { "code": "SUP-345702", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 389.44, "maximum": 2434.0, "setting": "outpatient", "gross_charge": 2434.0, "discounted_cash": 1703.8, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1243.77, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2248.51, "10th_percentile": 2248.51, "90th_percentile": 2248.51, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 1102.6, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1102.6, "10th_percentile": 1102.6, "90th_percentile": 1102.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1217.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1217.0, "10th_percentile": 1217.0, "90th_percentile": 1217.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1460.4, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1460.4, "10th_percentile": 1460.4, "90th_percentile": 1460.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1563.36, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1563.36, "10th_percentile": 1563.36, "90th_percentile": 1563.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1703.8, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1703.8, "10th_percentile": 1703.8, "90th_percentile": 1703.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2434.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2434.0, "10th_percentile": 2434.0, "90th_percentile": 2434.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2434.0, "10th_percentile": 2434.0, "90th_percentile": 2434.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2434.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2434.0, "10th_percentile": 2434.0, "90th_percentile": 2434.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2434.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2434.0, "10th_percentile": 2434.0, "90th_percentile": 2434.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2434.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2434.0, "10th_percentile": 2434.0, "90th_percentile": 2434.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 389.44, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 389.44, "10th_percentile": 389.44, "90th_percentile": 389.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 389.44, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 389.44, "10th_percentile": 389.44, "90th_percentile": 389.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 389.44, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 389.44, "10th_percentile": 389.44, "90th_percentile": 389.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1382.51, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1382.51, "10th_percentile": 1382.51, "90th_percentile": 1382.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1382.51, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1382.51, "10th_percentile": 1382.51, "90th_percentile": 1382.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2434.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,434.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2434.0, "10th_percentile": 2434.0, "90th_percentile": 2434.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,434.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 720.46, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 720.46, "10th_percentile": 720.46, "90th_percentile": 720.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1825.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1825.5, "10th_percentile": 1825.5, "90th_percentile": 1825.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 825.13, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 825.13, "10th_percentile": 825.13, "90th_percentile": 825.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1947.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1947.2, "10th_percentile": 1947.2, "90th_percentile": 1947.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1825.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1825.5, "10th_percentile": 1825.5, "90th_percentile": 1825.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 523.31, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 523.31, "10th_percentile": 523.31, "90th_percentile": 523.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1217.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1217.0, "10th_percentile": 1217.0, "90th_percentile": 1217.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1947.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1947.2, "10th_percentile": 1947.2, "90th_percentile": 1947.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 2068.9, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 2068.9, "10th_percentile": 2068.9, "90th_percentile": 2068.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 455.16, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 455.16, "10th_percentile": 455.16, "90th_percentile": 455.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 952.42, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 952.42, "10th_percentile": 952.42, "90th_percentile": 952.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 952.42, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 952.42, "10th_percentile": 952.42, "90th_percentile": 952.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 467.33, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 467.33, "10th_percentile": 467.33, "90th_percentile": 467.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 467.33, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 467.33, "10th_percentile": 467.33, "90th_percentile": 467.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2434.0, "10th_percentile": 2434.0, "90th_percentile": 2434.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2434.0, "10th_percentile": 2434.0, "90th_percentile": 2434.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2434.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2434.0, "10th_percentile": 2434.0, "90th_percentile": 2434.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2434.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2434.0, "10th_percentile": 2434.0, "90th_percentile": 2434.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2434.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2434.0, "10th_percentile": 2434.0, "90th_percentile": 2434.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2434.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2434.0, "10th_percentile": 2434.0, "90th_percentile": 2434.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2434.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2434.0, "10th_percentile": 2434.0, "90th_percentile": 2434.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC", "code_information": [ { "code": "726", "type": "MS-DRG" } ], "standard_charges": [ { "minimum": 5137.63, "maximum": 10515.93, "setting": "inpatient", "gross_charge": 21073.5, "discounted_cash": 14751.45, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_dollar": 5137.63, "standard_charge_algorithm": "Re-evaluated: HLB.787113995; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.72, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $5,454.76; Additional payment reduction: $54.55; Total: $5,400.21", "median_amount": 5400.21, "10th_percentile": 5400.21, "90th_percentile": 5400.21, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.787113995; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.72, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $5,454.76; Additional payment reduction: $54.55; Total: $5,400.21" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_dollar": 5137.63, "standard_charge_algorithm": "Re-evaluated: HLB.787113995; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.72, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $5,454.76; Additional payment reduction: $54.55; Total: $5,400.21", "median_amount": 5400.21, "10th_percentile": 5400.21, "90th_percentile": 5400.21, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.787113995; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All DRGs; FSC: NM HB MEDICARE ACUTE WEIGHTED, Value: 0.72, and; Pricing Extension - NM HB XR PRC - Medicare IP DRG Calculation; Note: Base payment: $5,454.76; Additional payment reduction: $54.55; Total: $5,400.21" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.787113995; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; 100% Billed", "median_amount": 21063.75, "10th_percentile": 21063.75, "90th_percentile": 21063.75, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.787113995; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; 100% Billed", "median_amount": 21063.75, "10th_percentile": 21063.75, "90th_percentile": 21063.75, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.787113995; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; 100% Billed", "median_amount": 21063.75, "10th_percentile": 21063.75, "90th_percentile": 21063.75, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.787113995; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; 100% Billed", "median_amount": 21063.75, "10th_percentile": 21063.75, "90th_percentile": 21063.75, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.787113995; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; 100% Billed", "median_amount": 21063.75, "10th_percentile": 21063.75, "90th_percentile": 21063.75, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.787113995; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; 100% Billed", "median_amount": 21063.75, "10th_percentile": 21063.75, "90th_percentile": 21063.75, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.787113995; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; 100% Billed", "median_amount": 21063.75, "10th_percentile": 21063.75, "90th_percentile": 21063.75, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.787113995; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; 100% Billed", "median_amount": 21063.75, "10th_percentile": 21063.75, "90th_percentile": 21063.75, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.787113995; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services - OON; 100% Billed", "median_amount": 21063.75, "10th_percentile": 21063.75, "90th_percentile": 21063.75, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Re-evaluated: HLB.787113995; Using historical claim(s); Scope: All Financial Classes; Cases: 4; INPATIENT; 80% Billed", "median_amount": 16851.0, "10th_percentile": 16851.0, "90th_percentile": 16851.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Re-evaluated: HLB.787113995; Using historical claim(s); Scope: All Financial Classes; Cases: 4; Inpatient; 80% Billed", "median_amount": 16851.0, "10th_percentile": 16851.0, "90th_percentile": 16851.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Additional drugs, labs, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 9942.63, "10th_percentile": 9942.63, "90th_percentile": 9942.63, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 30.4, "standard_charge_algorithm": "Re-evaluated: HLB.787113995; Using historical claim(s); Scope: All Financial Classes; Cases: 4; IP Services. ADP RATE (for patient estimates only); 30.4% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6403.38, "10th_percentile": 6403.38, "90th_percentile": 6403.38, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_percentage": 21.5, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 4528.74, "10th_percentile": 4528.74, "90th_percentile": 4528.74, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_percentage": 34.2, "standard_charge_algorithm": "Re-evaluated: HLB.787113995; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All Inpatient Services; 34.2% Billed", "median_amount": 7203.8, "10th_percentile": 7203.8, "90th_percentile": 7203.8, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Re-evaluated: HLB.787113995; Using historical claim(s); Scope: All Financial Classes; Cases: 4; Inpatient Services; 50% Billed", "median_amount": 10531.88, "10th_percentile": 10531.88, "90th_percentile": 10531.88, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional drugs, labs, radiology services, supplies, therapy services, and other services can be included in reimbursement.", "median_amount": 10531.88, "10th_percentile": 10531.88, "90th_percentile": 10531.88, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Re-evaluated: HLB.787113995; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; 75% Billed", "median_amount": 15797.81, "10th_percentile": 15797.81, "90th_percentile": 15797.81, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 10515.93, "standard_charge_algorithm": "Re-evaluated: HLB.787113995; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.7220, Rate: 14,565.00, and; Pricing Extension - NM HB XR PRC - PH BCBS PPO STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10515.93, "10th_percentile": 10515.93, "90th_percentile": 10515.93, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 7427.21, "standard_charge_algorithm": "Re-evaluated: HLB.787113995; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.7220, Rate: 10,287.00, and; Pricing Extension - NM HB XR PRC - PH BCBS HMO STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7427.21, "10th_percentile": 7427.21, "90th_percentile": 7427.21, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 7427.21, "standard_charge_algorithm": "Re-evaluated: HLB.787113995; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.7220, Rate: 10,287.00, and; Pricing Extension - NM HB XR PRC - PH BCBS HMO STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7427.21, "10th_percentile": 7427.21, "90th_percentile": 7427.21, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 10515.93, "standard_charge_algorithm": "Re-evaluated: HLB.787113995; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.7220, Rate: 14,565.00, and; Pricing Extension - NM HB XR PRC - PH BCBS PPO STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10515.93, "10th_percentile": 10515.93, "90th_percentile": 10515.93, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 6530.49, "standard_charge_algorithm": "Re-evaluated: HLB.787113995; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.7220, Rate: 9,045.00, and; Pricing Extension - NM HB XR PRC - PH BCBS CHOICE STOP LOSS & LESSOR OF 9.1.25; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6530.49, "10th_percentile": 6530.49, "90th_percentile": 6530.49, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 5779.61, "standard_charge_algorithm": "Re-evaluated: HLB.787113995; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.7220, Rate: 8,005.00, and; Pricing Extension - NM HB XR PRC - PH BCBS CHOICE SELECT STOP LOSS & LESSOR OF *; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5779.61, "10th_percentile": 5779.61, "90th_percentile": 5779.61, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 6183.93, "standard_charge_algorithm": "Re-evaluated: HLB.787113995; Using historical claim(s); Scope: All Financial Classes; Cases: 4; All IP Services; Weighted FSC: NM HB MEDICARE ACUTE WEIGHTED, Weight: 0.7220, Rate: 8,565.00, and; Pricing Extension - NM HB XR PRC - PH BCBS CHOICE PREF STOP LOSS & LESSOR OF 9.*; Note: Multiple pricing methods applied. Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6183.93, "10th_percentile": 6183.93, "90th_percentile": 6183.93, "count": "1 through 10", "methodology": "case rate" } ] } ] }, { "description": "BICALUTAMIDE 50 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-83888", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "41616-0485-83", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.89, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.89, "10th_percentile": 0.89, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.89, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.89, "10th_percentile": 0.89, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1.4, "10th_percentile": 1.4, "90th_percentile": 1.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.43, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.37, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.37, "10th_percentile": 0.37, "90th_percentile": 0.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1.2, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1.2, "10th_percentile": 1.2, "90th_percentile": 1.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.68, "10th_percentile": 0.68, "90th_percentile": 0.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.28, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.28, "10th_percentile": 0.28, "90th_percentile": 0.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1.7, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1.7, "10th_percentile": 1.7, "90th_percentile": 1.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.29, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.29, "10th_percentile": 0.29, "90th_percentile": 0.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.34, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.34, "10th_percentile": 0.34, "90th_percentile": 0.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.59, "10th_percentile": 0.59, "90th_percentile": 0.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1.28, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1.28, "10th_percentile": 1.28, "90th_percentile": 1.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 0.91, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.91, "10th_percentile": 0.91, "90th_percentile": 0.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1.02, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.02, "10th_percentile": 1.02, "90th_percentile": 1.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "BINDER BREAST LG BLU 933015BLUE/LG", "code_information": [ { "code": "SUP-310672", "type": "CDM" }, { "code": "27103350", "type": "LOCAL" }, { "code": "0271", "type": "RC" } ], "standard_charges": [ { "minimum": 10.5, "maximum": 75.02, "setting": "outpatient", "gross_charge": 75.02, "discounted_cash": 52.51, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 75.02, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 75.02, "10th_percentile": 75.02, "90th_percentile": 75.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 75.02, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 75.02, "10th_percentile": 75.02, "90th_percentile": 75.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 75.02, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 75.02, "10th_percentile": 75.02, "90th_percentile": 75.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 75.02, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 75.02, "10th_percentile": 75.02, "90th_percentile": 75.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 75.02, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 75.02, "10th_percentile": 75.02, "90th_percentile": 75.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 75.02, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 75.02, "10th_percentile": 75.02, "90th_percentile": 75.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 75.02, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 75.02, "10th_percentile": 75.02, "90th_percentile": 75.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 75.02, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 75.02, "10th_percentile": 75.02, "90th_percentile": 75.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 29.36, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 29.36, "10th_percentile": 29.36, "90th_percentile": 29.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 29.36, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 29.36, "10th_percentile": 29.36, "90th_percentile": 29.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 42.61, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 42.61, "10th_percentile": 42.61, "90th_percentile": 42.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 42.61, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 42.61, "10th_percentile": 42.61, "90th_percentile": 42.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 33.22, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33.22, "10th_percentile": 33.22, "90th_percentile": 33.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 33.22, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33.22, "10th_percentile": 33.22, "90th_percentile": 33.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 14.03, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.03, "10th_percentile": 14.03, "90th_percentile": 14.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 56.27, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 56.27, "10th_percentile": 56.27, "90th_percentile": 56.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 75.02, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $75.02 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 75.02, "10th_percentile": 75.02, "90th_percentile": 75.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $75.02 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 12.7, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.7, "10th_percentile": 12.7, "90th_percentile": 12.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 10.71, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.71, "10th_percentile": 10.71, "90th_percentile": 10.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 10.5, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.5, "10th_percentile": 10.5, "90th_percentile": 10.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 33.98, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33.98, "10th_percentile": 33.98, "90th_percentile": 33.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 45.01, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 45.01, "10th_percentile": 45.01, "90th_percentile": 45.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 52.51, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 52.51, "10th_percentile": 52.51, "90th_percentile": 52.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 48.19, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 48.19, "10th_percentile": 48.19, "90th_percentile": 48.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 63.77, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 63.77, "10th_percentile": 63.77, "90th_percentile": 63.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 38.34, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.34, "10th_percentile": 38.34, "90th_percentile": 38.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 56.27, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 56.27, "10th_percentile": 56.27, "90th_percentile": 56.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 75.02, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 75.02, "10th_percentile": 75.02, "90th_percentile": 75.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 37.51, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 37.51, "10th_percentile": 37.51, "90th_percentile": 37.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 60.02, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 60.02, "10th_percentile": 60.02, "90th_percentile": 60.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 22.21, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 22.21, "10th_percentile": 22.21, "90th_percentile": 22.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 37.51, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 37.51, "10th_percentile": 37.51, "90th_percentile": 37.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 25.43, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 25.43, "10th_percentile": 25.43, "90th_percentile": 25.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 16.13, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 16.13, "10th_percentile": 16.13, "90th_percentile": 16.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 60.02, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 60.02, "10th_percentile": 60.02, "90th_percentile": 60.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 75.02, "10th_percentile": 75.02, "90th_percentile": 75.02, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 75.02, "10th_percentile": 75.02, "90th_percentile": 75.02, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 75.02, "10th_percentile": 75.02, "90th_percentile": 75.02, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "BIOPATCH DRESSING (4150)", "code_information": [ { "code": "SUP-304467", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 2.01, "maximum": 14.35, "setting": "outpatient", "gross_charge": 14.35, "discounted_cash": 10.04, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 5.62, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.62, "10th_percentile": 5.62, "90th_percentile": 5.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 5.62, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.62, "10th_percentile": 5.62, "90th_percentile": 5.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 6.35, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.35, "10th_percentile": 6.35, "90th_percentile": 6.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 6.35, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.35, "10th_percentile": 6.35, "90th_percentile": 6.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 8.15, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.15, "10th_percentile": 8.15, "90th_percentile": 8.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 8.15, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.15, "10th_percentile": 8.15, "90th_percentile": 8.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 10.76, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 10.76, "10th_percentile": 10.76, "90th_percentile": 10.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 3.09, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 3.09, "10th_percentile": 3.09, "90th_percentile": 3.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 4.86, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 4.86, "10th_percentile": 4.86, "90th_percentile": 4.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 10.05, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 10.05, "10th_percentile": 10.05, "90th_percentile": 10.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 10.76, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 10.76, "10th_percentile": 10.76, "90th_percentile": 10.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 7.18, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.18, "10th_percentile": 7.18, "90th_percentile": 7.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 7.18, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 7.18, "10th_percentile": 7.18, "90th_percentile": 7.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 11.48, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 11.48, "10th_percentile": 11.48, "90th_percentile": 11.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 8.61, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 8.61, "10th_percentile": 8.61, "90th_percentile": 8.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 9.22, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 9.22, "10th_percentile": 9.22, "90th_percentile": 9.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 12.2, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 12.2, "10th_percentile": 12.2, "90th_percentile": 12.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 6.5, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.5, "10th_percentile": 6.5, "90th_percentile": 6.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 7.33, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.33, "10th_percentile": 7.33, "90th_percentile": 7.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 14.35, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 14.35, "10th_percentile": 14.35, "90th_percentile": 14.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 2.68, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.68, "10th_percentile": 2.68, "90th_percentile": 2.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 11.48, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.48, "10th_percentile": 11.48, "90th_percentile": 11.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 4.25, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.25, "10th_percentile": 4.25, "90th_percentile": 4.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 14.35, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $14.35 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 14.35, "10th_percentile": 14.35, "90th_percentile": 14.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $14.35 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2.43, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.43, "10th_percentile": 2.43, "90th_percentile": 2.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 2.01, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.01, "10th_percentile": 2.01, "90th_percentile": 2.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2.05, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.05, "10th_percentile": 2.05, "90th_percentile": 2.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 14.35, "10th_percentile": 14.35, "90th_percentile": 14.35, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 14.35, "10th_percentile": 14.35, "90th_percentile": 14.35, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 14.35, "10th_percentile": 14.35, "90th_percentile": 14.35, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 14.35, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 14.35, "10th_percentile": 14.35, "90th_percentile": 14.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 14.35, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 14.35, "10th_percentile": 14.35, "90th_percentile": 14.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 14.35, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 14.35, "10th_percentile": 14.35, "90th_percentile": 14.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 14.35, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 14.35, "10th_percentile": 14.35, "90th_percentile": 14.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 14.35, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 14.35, "10th_percentile": 14.35, "90th_percentile": 14.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 14.35, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 14.35, "10th_percentile": 14.35, "90th_percentile": 14.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 14.35, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 14.35, "10th_percentile": 14.35, "90th_percentile": 14.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 14.35, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 14.35, "10th_percentile": 14.35, "90th_percentile": 14.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BIOSYN 2-0 KV-34 30IN UD CM827", "code_information": [ { "code": "SUP-380944", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 3.12, "maximum": 22.27, "setting": "outpatient", "gross_charge": 22.27, "discounted_cash": 15.59, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3.77, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.77, "10th_percentile": 3.77, "90th_percentile": 3.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 3.18, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.18, "10th_percentile": 3.18, "90th_percentile": 3.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 3.12, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.12, "10th_percentile": 3.12, "90th_percentile": 3.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 7.55, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 7.55, "10th_percentile": 7.55, "90th_percentile": 7.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 4.79, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 4.79, "10th_percentile": 4.79, "90th_percentile": 4.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 8.71, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.71, "10th_percentile": 8.71, "90th_percentile": 8.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 9.86, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.86, "10th_percentile": 9.86, "90th_percentile": 9.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 17.82, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 17.82, "10th_percentile": 17.82, "90th_percentile": 17.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 12.65, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.65, "10th_percentile": 12.65, "90th_percentile": 12.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 22.27, "10th_percentile": 22.27, "90th_percentile": 22.27, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 22.27, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 22.27, "10th_percentile": 22.27, "90th_percentile": 22.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 9.86, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.86, "10th_percentile": 9.86, "90th_percentile": 9.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 8.71, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.71, "10th_percentile": 8.71, "90th_percentile": 8.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 22.27, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $22.27 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 22.27, "10th_percentile": 22.27, "90th_percentile": 22.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $22.27 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 18.93, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 18.93, "10th_percentile": 18.93, "90th_percentile": 18.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 14.3, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 14.3, "10th_percentile": 14.3, "90th_percentile": 14.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 11.14, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 11.14, "10th_percentile": 11.14, "90th_percentile": 11.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 15.59, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 15.59, "10th_percentile": 15.59, "90th_percentile": 15.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 16.7, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 16.7, "10th_percentile": 16.7, "90th_percentile": 16.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 11.14, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.14, "10th_percentile": 11.14, "90th_percentile": 11.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 13.36, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 13.36, "10th_percentile": 13.36, "90th_percentile": 13.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 16.7, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 16.7, "10th_percentile": 16.7, "90th_percentile": 16.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 6.59, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.59, "10th_percentile": 6.59, "90th_percentile": 6.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 4.16, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.16, "10th_percentile": 4.16, "90th_percentile": 4.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 17.82, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17.82, "10th_percentile": 17.82, "90th_percentile": 17.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 22.27, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 22.27, "10th_percentile": 22.27, "90th_percentile": 22.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 10.09, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.09, "10th_percentile": 10.09, "90th_percentile": 10.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 11.38, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.38, "10th_percentile": 11.38, "90th_percentile": 11.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 12.65, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.65, "10th_percentile": 12.65, "90th_percentile": 12.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 22.27, "10th_percentile": 22.27, "90th_percentile": 22.27, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 22.27, "10th_percentile": 22.27, "90th_percentile": 22.27, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 22.27, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 22.27, "10th_percentile": 22.27, "90th_percentile": 22.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 22.27, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 22.27, "10th_percentile": 22.27, "90th_percentile": 22.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 22.27, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 22.27, "10th_percentile": 22.27, "90th_percentile": 22.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 22.27, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 22.27, "10th_percentile": 22.27, "90th_percentile": 22.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 22.27, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 22.27, "10th_percentile": 22.27, "90th_percentile": 22.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 22.27, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 22.27, "10th_percentile": 22.27, "90th_percentile": 22.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 22.27, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 22.27, "10th_percentile": 22.27, "90th_percentile": 22.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BISACODYL 10 MG RECT SUPP", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-1080", "type": "CDM" }, { "code": "J3490", "type": "HCPCS" }, { "code": "0637", "type": "RC" }, { "code": "00574-7050-50", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.32, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1.4, "10th_percentile": 1.4, "90th_percentile": 1.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1.2, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1.2, "10th_percentile": 1.2, "90th_percentile": 1.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1.02, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.02, "10th_percentile": 1.02, "90th_percentile": 1.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1.28, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1.28, "10th_percentile": 1.28, "90th_percentile": 1.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1.7, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1.7, "10th_percentile": 1.7, "90th_percentile": 1.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 0.91, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.91, "10th_percentile": 0.91, "90th_percentile": 0.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.43, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.68, "10th_percentile": 0.68, "90th_percentile": 0.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.38, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.38, "10th_percentile": 0.38, "90th_percentile": 0.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.38, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.38, "10th_percentile": 0.38, "90th_percentile": 0.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.32, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.32, "10th_percentile": 0.32, "90th_percentile": 0.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.32, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.32, "10th_percentile": 0.32, "90th_percentile": 0.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.32, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.32, "10th_percentile": 0.32, "90th_percentile": 0.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "BIT DRILL 4.5/6.5MM 485MM TI STEPPED RECON 03.010.078", "code_information": [ { "code": "SUP-344359", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 130.69, "maximum": 934.15, "setting": "outpatient", "gross_charge": 934.15, "discounted_cash": 653.9, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 158.15, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 158.15, "10th_percentile": 158.15, "90th_percentile": 158.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 413.64, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 413.64, "10th_percentile": 413.64, "90th_percentile": 413.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 365.53, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 365.53, "10th_percentile": 365.53, "90th_percentile": 365.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 133.3, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 133.3, "10th_percentile": 133.3, "90th_percentile": 133.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 130.69, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 130.69, "10th_percentile": 130.69, "90th_percentile": 130.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 934.15, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $934.15 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 934.15, "10th_percentile": 934.15, "90th_percentile": 934.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $934.15 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 794.03, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 794.03, "10th_percentile": 794.03, "90th_percentile": 794.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 600.0, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 600.0, "10th_percentile": 600.0, "90th_percentile": 600.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 467.08, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 467.08, "10th_percentile": 467.08, "90th_percentile": 467.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 316.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 316.68, "10th_percentile": 316.68, "90th_percentile": 316.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 653.91, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 653.91, "10th_percentile": 653.91, "90th_percentile": 653.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 700.61, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 700.61, "10th_percentile": 700.61, "90th_percentile": 700.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 413.64, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 413.64, "10th_percentile": 413.64, "90th_percentile": 413.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 467.08, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 467.08, "10th_percentile": 467.08, "90th_percentile": 467.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 747.32, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 747.32, "10th_percentile": 747.32, "90th_percentile": 747.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 560.49, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 560.49, "10th_percentile": 560.49, "90th_percentile": 560.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 200.84, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 200.84, "10th_percentile": 200.84, "90th_percentile": 200.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 365.53, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 365.53, "10th_percentile": 365.53, "90th_percentile": 365.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 700.61, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 700.61, "10th_percentile": 700.61, "90th_percentile": 700.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 276.51, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 276.51, "10th_percentile": 276.51, "90th_percentile": 276.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 174.69, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 174.69, "10th_percentile": 174.69, "90th_percentile": 174.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 747.32, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 747.32, "10th_percentile": 747.32, "90th_percentile": 747.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 934.15, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 934.15, "10th_percentile": 934.15, "90th_percentile": 934.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 423.17, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 423.17, "10th_percentile": 423.17, "90th_percentile": 423.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 477.35, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 477.35, "10th_percentile": 477.35, "90th_percentile": 477.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 530.6, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 530.6, "10th_percentile": 530.6, "90th_percentile": 530.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 530.6, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 530.6, "10th_percentile": 530.6, "90th_percentile": 530.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 934.15, "10th_percentile": 934.15, "90th_percentile": 934.15, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 934.15, "10th_percentile": 934.15, "90th_percentile": 934.15, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 934.15, "10th_percentile": 934.15, "90th_percentile": 934.15, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 934.15, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 934.15, "10th_percentile": 934.15, "90th_percentile": 934.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 934.15, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 934.15, "10th_percentile": 934.15, "90th_percentile": 934.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 934.15, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 934.15, "10th_percentile": 934.15, "90th_percentile": 934.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 934.15, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 934.15, "10th_percentile": 934.15, "90th_percentile": 934.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 934.15, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 934.15, "10th_percentile": 934.15, "90th_percentile": 934.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 934.15, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 934.15, "10th_percentile": 934.15, "90th_percentile": 934.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 934.15, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 934.15, "10th_percentile": 934.15, "90th_percentile": 934.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 934.15, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 934.15, "10th_percentile": 934.15, "90th_percentile": 934.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BIT DRILL 60X145MM 1.8 VOLT", "code_information": [ { "code": "SUP-450989", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 64.83, "maximum": 463.43, "setting": "outpatient", "gross_charge": 463.43, "discounted_cash": 324.4, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 181.34, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 181.34, "10th_percentile": 181.34, "90th_percentile": 181.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 205.21, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 205.21, "10th_percentile": 205.21, "90th_percentile": 205.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 263.23, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 263.23, "10th_percentile": 263.23, "90th_percentile": 263.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 347.57, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 347.57, "10th_percentile": 347.57, "90th_percentile": 347.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 324.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 324.4, "10th_percentile": 324.4, "90th_percentile": 324.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 347.57, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 347.57, "10th_percentile": 347.57, "90th_percentile": 347.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 231.72, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 231.72, "10th_percentile": 231.72, "90th_percentile": 231.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 231.72, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 231.72, "10th_percentile": 231.72, "90th_percentile": 231.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 370.74, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 370.74, "10th_percentile": 370.74, "90th_percentile": 370.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 278.06, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 278.06, "10th_percentile": 278.06, "90th_percentile": 278.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 297.66, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 297.66, "10th_percentile": 297.66, "90th_percentile": 297.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 393.92, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 393.92, "10th_percentile": 393.92, "90th_percentile": 393.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 209.93, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 209.93, "10th_percentile": 209.93, "90th_percentile": 209.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 236.81, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 236.81, "10th_percentile": 236.81, "90th_percentile": 236.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 463.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 463.43, "10th_percentile": 463.43, "90th_percentile": 463.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 86.66, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 86.66, "10th_percentile": 86.66, "90th_percentile": 86.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 370.74, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 370.74, "10th_percentile": 370.74, "90th_percentile": 370.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 137.18, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 137.18, "10th_percentile": 137.18, "90th_percentile": 137.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 463.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $463.43 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 463.43, "10th_percentile": 463.43, "90th_percentile": 463.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $463.43 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 78.46, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 78.46, "10th_percentile": 78.46, "90th_percentile": 78.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 64.83, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 64.83, "10th_percentile": 64.83, "90th_percentile": 64.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 66.13, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 66.13, "10th_percentile": 66.13, "90th_percentile": 66.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 463.43, "10th_percentile": 463.43, "90th_percentile": 463.43, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 463.43, "10th_percentile": 463.43, "90th_percentile": 463.43, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 463.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 463.43, "10th_percentile": 463.43, "90th_percentile": 463.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 463.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 463.43, "10th_percentile": 463.43, "90th_percentile": 463.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 463.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 463.43, "10th_percentile": 463.43, "90th_percentile": 463.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 463.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 463.43, "10th_percentile": 463.43, "90th_percentile": 463.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 463.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 463.43, "10th_percentile": 463.43, "90th_percentile": 463.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 463.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 463.43, "10th_percentile": 463.43, "90th_percentile": 463.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 463.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 463.43, "10th_percentile": 463.43, "90th_percentile": 463.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 157.1, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 157.1, "10th_percentile": 157.1, "90th_percentile": 157.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 205.21, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 205.21, "10th_percentile": 205.21, "90th_percentile": 205.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 99.64, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 99.64, "10th_percentile": 99.64, "90th_percentile": 99.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 181.34, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 181.34, "10th_percentile": 181.34, "90th_percentile": 181.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 263.23, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 263.23, "10th_percentile": 263.23, "90th_percentile": 263.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 463.43, "10th_percentile": 463.43, "90th_percentile": 463.43, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 463.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 463.43, "10th_percentile": 463.43, "90th_percentile": 463.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BIT DRLL 1.8X130MM AO QUICK CONNECT", "code_information": [ { "code": "SUP-449696", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 38.53, "maximum": 275.43, "setting": "outpatient", "gross_charge": 275.43, "discounted_cash": 192.8, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 107.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 107.78, "10th_percentile": 107.78, "90th_percentile": 107.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 46.63, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 46.63, "10th_percentile": 46.63, "90th_percentile": 46.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 39.3, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.3, "10th_percentile": 39.3, "90th_percentile": 39.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 38.53, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.53, "10th_percentile": 38.53, "90th_percentile": 38.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 121.96, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 121.96, "10th_percentile": 121.96, "90th_percentile": 121.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 275.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $275.43 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 275.43, "10th_percentile": 275.43, "90th_percentile": 275.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $275.43 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 93.37, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 93.37, "10th_percentile": 93.37, "90th_percentile": 93.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 59.22, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 59.22, "10th_percentile": 59.22, "90th_percentile": 59.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 206.57, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 206.57, "10th_percentile": 206.57, "90th_percentile": 206.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 206.57, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 206.57, "10th_percentile": 206.57, "90th_percentile": 206.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 107.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 107.78, "10th_percentile": 107.78, "90th_percentile": 107.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 234.12, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 234.12, "10th_percentile": 234.12, "90th_percentile": 234.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 192.8, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 192.8, "10th_percentile": 192.8, "90th_percentile": 192.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 137.72, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 137.72, "10th_percentile": 137.72, "90th_percentile": 137.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 137.72, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 137.72, "10th_percentile": 137.72, "90th_percentile": 137.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 165.26, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 165.26, "10th_percentile": 165.26, "90th_percentile": 165.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 176.91, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 176.91, "10th_percentile": 176.91, "90th_percentile": 176.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 121.96, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 121.96, "10th_percentile": 121.96, "90th_percentile": 121.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 220.34, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 220.34, "10th_percentile": 220.34, "90th_percentile": 220.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 51.51, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 51.51, "10th_percentile": 51.51, "90th_percentile": 51.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 81.53, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 81.53, "10th_percentile": 81.53, "90th_percentile": 81.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 220.34, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 220.34, "10th_percentile": 220.34, "90th_percentile": 220.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 275.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 275.43, "10th_percentile": 275.43, "90th_percentile": 275.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 124.77, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 124.77, "10th_percentile": 124.77, "90th_percentile": 124.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 140.74, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 140.74, "10th_percentile": 140.74, "90th_percentile": 140.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 156.44, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 156.44, "10th_percentile": 156.44, "90th_percentile": 156.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 156.44, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 156.44, "10th_percentile": 156.44, "90th_percentile": 156.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 275.43, "10th_percentile": 275.43, "90th_percentile": 275.43, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 275.43, "10th_percentile": 275.43, "90th_percentile": 275.43, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 275.43, "10th_percentile": 275.43, "90th_percentile": 275.43, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 275.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 275.43, "10th_percentile": 275.43, "90th_percentile": 275.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 275.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 275.43, "10th_percentile": 275.43, "90th_percentile": 275.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 275.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 275.43, "10th_percentile": 275.43, "90th_percentile": 275.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 275.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 275.43, "10th_percentile": 275.43, "90th_percentile": 275.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 275.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 275.43, "10th_percentile": 275.43, "90th_percentile": 275.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 275.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 275.43, "10th_percentile": 275.43, "90th_percentile": 275.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 275.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 275.43, "10th_percentile": 275.43, "90th_percentile": 275.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 275.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 275.43, "10th_percentile": 275.43, "90th_percentile": 275.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BIT DRLL 135X45MM QC CLBRTN STRL", "code_information": [ { "code": "SUP-432981", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 51.04, "maximum": 364.81, "setting": "outpatient", "gross_charge": 364.81, "discounted_cash": 255.37, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 61.76, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 61.76, "10th_percentile": 61.76, "90th_percentile": 61.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 161.54, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 161.54, "10th_percentile": 161.54, "90th_percentile": 161.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 142.75, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 142.75, "10th_percentile": 142.75, "90th_percentile": 142.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 52.06, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 52.06, "10th_percentile": 52.06, "90th_percentile": 52.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 51.04, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 51.04, "10th_percentile": 51.04, "90th_percentile": 51.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 364.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $364.81 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 364.81, "10th_percentile": 364.81, "90th_percentile": 364.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $364.81 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 310.09, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 310.09, "10th_percentile": 310.09, "90th_percentile": 310.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 234.32, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 234.32, "10th_percentile": 234.32, "90th_percentile": 234.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 182.41, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 182.41, "10th_percentile": 182.41, "90th_percentile": 182.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 123.67, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 123.67, "10th_percentile": 123.67, "90th_percentile": 123.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 255.37, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 255.37, "10th_percentile": 255.37, "90th_percentile": 255.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 273.61, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 273.61, "10th_percentile": 273.61, "90th_percentile": 273.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 161.54, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 161.54, "10th_percentile": 161.54, "90th_percentile": 161.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 182.41, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 182.41, "10th_percentile": 182.41, "90th_percentile": 182.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 291.85, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 291.85, "10th_percentile": 291.85, "90th_percentile": 291.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 218.89, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 218.89, "10th_percentile": 218.89, "90th_percentile": 218.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 78.43, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 78.43, "10th_percentile": 78.43, "90th_percentile": 78.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 142.75, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 142.75, "10th_percentile": 142.75, "90th_percentile": 142.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 273.61, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 273.61, "10th_percentile": 273.61, "90th_percentile": 273.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 107.98, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 107.98, "10th_percentile": 107.98, "90th_percentile": 107.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 68.22, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 68.22, "10th_percentile": 68.22, "90th_percentile": 68.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 291.85, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 291.85, "10th_percentile": 291.85, "90th_percentile": 291.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 364.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 364.81, "10th_percentile": 364.81, "90th_percentile": 364.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 165.26, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 165.26, "10th_percentile": 165.26, "90th_percentile": 165.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 186.42, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 186.42, "10th_percentile": 186.42, "90th_percentile": 186.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 207.21, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 207.21, "10th_percentile": 207.21, "90th_percentile": 207.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 207.21, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 207.21, "10th_percentile": 207.21, "90th_percentile": 207.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 364.81, "10th_percentile": 364.81, "90th_percentile": 364.81, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 364.81, "10th_percentile": 364.81, "90th_percentile": 364.81, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 364.81, "10th_percentile": 364.81, "90th_percentile": 364.81, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 364.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 364.81, "10th_percentile": 364.81, "90th_percentile": 364.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 364.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 364.81, "10th_percentile": 364.81, "90th_percentile": 364.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 364.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 364.81, "10th_percentile": 364.81, "90th_percentile": 364.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 364.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 364.81, "10th_percentile": 364.81, "90th_percentile": 364.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 364.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 364.81, "10th_percentile": 364.81, "90th_percentile": 364.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 364.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 364.81, "10th_percentile": 364.81, "90th_percentile": 364.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 364.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 364.81, "10th_percentile": 364.81, "90th_percentile": 364.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 364.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 364.81, "10th_percentile": 364.81, "90th_percentile": 364.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BIT DRLL 2.5X110MM AO QCK CNNCT", "code_information": [ { "code": "SUP-434563", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 24.12, "maximum": 172.44, "setting": "outpatient", "gross_charge": 172.44, "discounted_cash": 120.71, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 67.48, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 67.48, "10th_percentile": 67.48, "90th_percentile": 67.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 29.19, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 29.19, "10th_percentile": 29.19, "90th_percentile": 29.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 24.61, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.61, "10th_percentile": 24.61, "90th_percentile": 24.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 24.12, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.12, "10th_percentile": 24.12, "90th_percentile": 24.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 76.36, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 76.36, "10th_percentile": 76.36, "90th_percentile": 76.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 172.44, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $172.44 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 172.44, "10th_percentile": 172.44, "90th_percentile": 172.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $172.44 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 58.46, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 58.46, "10th_percentile": 58.46, "90th_percentile": 58.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 37.07, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 37.07, "10th_percentile": 37.07, "90th_percentile": 37.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 129.33, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 129.33, "10th_percentile": 129.33, "90th_percentile": 129.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 129.33, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 129.33, "10th_percentile": 129.33, "90th_percentile": 129.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 67.48, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 67.48, "10th_percentile": 67.48, "90th_percentile": 67.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 146.57, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 146.57, "10th_percentile": 146.57, "90th_percentile": 146.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 120.71, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 120.71, "10th_percentile": 120.71, "90th_percentile": 120.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 86.22, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 86.22, "10th_percentile": 86.22, "90th_percentile": 86.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 86.22, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 86.22, "10th_percentile": 86.22, "90th_percentile": 86.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 103.46, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 103.46, "10th_percentile": 103.46, "90th_percentile": 103.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 110.76, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 110.76, "10th_percentile": 110.76, "90th_percentile": 110.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 76.36, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 76.36, "10th_percentile": 76.36, "90th_percentile": 76.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 137.95, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 137.95, "10th_percentile": 137.95, "90th_percentile": 137.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 32.25, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 32.25, "10th_percentile": 32.25, "90th_percentile": 32.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 51.04, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 51.04, "10th_percentile": 51.04, "90th_percentile": 51.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 137.95, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 137.95, "10th_percentile": 137.95, "90th_percentile": 137.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 172.44, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 172.44, "10th_percentile": 172.44, "90th_percentile": 172.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 78.12, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 78.12, "10th_percentile": 78.12, "90th_percentile": 78.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 88.12, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 88.12, "10th_percentile": 88.12, "90th_percentile": 88.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 97.95, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 97.95, "10th_percentile": 97.95, "90th_percentile": 97.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 97.95, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 97.95, "10th_percentile": 97.95, "90th_percentile": 97.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 172.44, "10th_percentile": 172.44, "90th_percentile": 172.44, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 172.44, "10th_percentile": 172.44, "90th_percentile": 172.44, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 172.44, "10th_percentile": 172.44, "90th_percentile": 172.44, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 172.44, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 172.44, "10th_percentile": 172.44, "90th_percentile": 172.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 172.44, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 172.44, "10th_percentile": 172.44, "90th_percentile": 172.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 172.44, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 172.44, "10th_percentile": 172.44, "90th_percentile": 172.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 172.44, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 172.44, "10th_percentile": 172.44, "90th_percentile": 172.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 172.44, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 172.44, "10th_percentile": 172.44, "90th_percentile": 172.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 172.44, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 172.44, "10th_percentile": 172.44, "90th_percentile": 172.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 172.44, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 172.44, "10th_percentile": 172.44, "90th_percentile": 172.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 172.44, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 172.44, "10th_percentile": 172.44, "90th_percentile": 172.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BIT DRLL 215X5MM CNNLTD LG QCK CPLNG STRL", "code_information": [ { "code": "SUP-433849", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 162.94, "maximum": 1164.66, "setting": "outpatient", "gross_charge": 1164.66, "discounted_cash": 815.26, "payers_information": [ { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 661.53, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 661.53, "10th_percentile": 661.53, "90th_percentile": 661.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 873.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 873.5, "10th_percentile": 873.5, "90th_percentile": 873.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 815.26, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 815.26, "10th_percentile": 815.26, "90th_percentile": 815.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 873.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 873.5, "10th_percentile": 873.5, "90th_percentile": 873.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 582.33, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 582.33, "10th_percentile": 582.33, "90th_percentile": 582.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 698.8, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 698.8, "10th_percentile": 698.8, "90th_percentile": 698.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 748.06, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 748.06, "10th_percentile": 748.06, "90th_percentile": 748.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 989.96, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 989.96, "10th_percentile": 989.96, "90th_percentile": 989.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 527.59, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 527.59, "10th_percentile": 527.59, "90th_percentile": 527.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 595.14, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 595.14, "10th_percentile": 595.14, "90th_percentile": 595.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1164.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1164.66, "10th_percentile": 1164.66, "90th_percentile": 1164.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 217.79, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 217.79, "10th_percentile": 217.79, "90th_percentile": 217.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 931.73, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 931.73, "10th_percentile": 931.73, "90th_percentile": 931.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 344.74, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 344.74, "10th_percentile": 344.74, "90th_percentile": 344.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1164.66, "10th_percentile": 1164.66, "90th_percentile": 1164.66, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1164.66, "10th_percentile": 1164.66, "90th_percentile": 1164.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1164.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1164.66, "10th_percentile": 1164.66, "90th_percentile": 1164.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1164.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1164.66, "10th_percentile": 1164.66, "90th_percentile": 1164.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1164.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1164.66, "10th_percentile": 1164.66, "90th_percentile": 1164.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1164.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1164.66, "10th_percentile": 1164.66, "90th_percentile": 1164.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1164.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1164.66, "10th_percentile": 1164.66, "90th_percentile": 1164.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1164.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1164.66, "10th_percentile": 1164.66, "90th_percentile": 1164.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1164.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1164.66, "10th_percentile": 1164.66, "90th_percentile": 1164.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 455.73, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 455.73, "10th_percentile": 455.73, "90th_percentile": 455.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 197.18, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 197.18, "10th_percentile": 197.18, "90th_percentile": 197.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 166.2, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 166.2, "10th_percentile": 166.2, "90th_percentile": 166.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 162.94, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 162.94, "10th_percentile": 162.94, "90th_percentile": 162.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 515.71, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 515.71, "10th_percentile": 515.71, "90th_percentile": 515.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1164.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,164.66 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1164.66, "10th_percentile": 1164.66, "90th_percentile": 1164.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,164.66 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 394.82, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 394.82, "10th_percentile": 394.82, "90th_percentile": 394.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 250.4, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 250.4, "10th_percentile": 250.4, "90th_percentile": 250.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 455.73, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 455.73, "10th_percentile": 455.73, "90th_percentile": 455.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 582.33, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 582.33, "10th_percentile": 582.33, "90th_percentile": 582.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 515.71, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 515.71, "10th_percentile": 515.71, "90th_percentile": 515.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 931.73, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 931.73, "10th_percentile": 931.73, "90th_percentile": 931.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 661.53, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 661.53, "10th_percentile": 661.53, "90th_percentile": 661.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1164.66, "10th_percentile": 1164.66, "90th_percentile": 1164.66, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1164.66, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1164.66, "10th_percentile": 1164.66, "90th_percentile": 1164.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BIVALIRUDIN 250 MG IV SOLR", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-29396", "type": "CDM" }, { "code": "J0583", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "63323-0562-10", "type": "NDC" } ], "standard_charges": [ { "minimum": 30.12, "maximum": 188.25, "setting": "outpatient", "gross_charge": 188.25, "discounted_cash": 131.77, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 188.25, "10th_percentile": 188.25, "90th_percentile": 188.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 188.25, "10th_percentile": 188.25, "90th_percentile": 188.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 188.25, "10th_percentile": 188.25, "90th_percentile": 188.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 188.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $188.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 188.25, "10th_percentile": 188.25, "90th_percentile": 188.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $188.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 40.47, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 40.47, "10th_percentile": 40.47, "90th_percentile": 40.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 150.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 150.6, "10th_percentile": 150.6, "90th_percentile": 150.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 112.95, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 112.95, "10th_percentile": 112.95, "90th_percentile": 112.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 141.19, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 141.19, "10th_percentile": 141.19, "90th_percentile": 141.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 63.82, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 63.82, "10th_percentile": 63.82, "90th_percentile": 63.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 131.78, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 131.78, "10th_percentile": 131.78, "90th_percentile": 131.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 94.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 94.13, "10th_percentile": 94.13, "90th_percentile": 94.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 160.01, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 160.01, "10th_percentile": 160.01, "90th_percentile": 160.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 141.19, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 141.19, "10th_percentile": 141.19, "90th_percentile": 141.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 94.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 94.13, "10th_percentile": 94.13, "90th_percentile": 94.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 188.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 188.25, "10th_percentile": 188.25, "90th_percentile": 188.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 150.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 150.6, "10th_percentile": 150.6, "90th_percentile": 150.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 36.14, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.14, "10th_percentile": 36.14, "90th_percentile": 36.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 36.14, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.14, "10th_percentile": 36.14, "90th_percentile": 36.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 73.66, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 73.66, "10th_percentile": 73.66, "90th_percentile": 73.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 73.66, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 73.66, "10th_percentile": 73.66, "90th_percentile": 73.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 30.12, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 30.12, "10th_percentile": 30.12, "90th_percentile": 30.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 30.12, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 30.12, "10th_percentile": 30.12, "90th_percentile": 30.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 30.12, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 30.12, "10th_percentile": 30.12, "90th_percentile": 30.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 188.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 188.25, "10th_percentile": 188.25, "90th_percentile": 188.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 188.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 188.25, "10th_percentile": 188.25, "90th_percentile": 188.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 188.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 188.25, "10th_percentile": 188.25, "90th_percentile": 188.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 188.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 188.25, "10th_percentile": 188.25, "90th_percentile": 188.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 188.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 188.25, "10th_percentile": 188.25, "90th_percentile": 188.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 188.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 188.25, "10th_percentile": 188.25, "90th_percentile": 188.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 188.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 188.25, "10th_percentile": 188.25, "90th_percentile": 188.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 188.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 188.25, "10th_percentile": 188.25, "90th_percentile": 188.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BIVALIRUDIN 250 MG IV SOLR", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-29396", "type": "CDM" }, { "code": "J0583", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "67457-0256-10", "type": "NDC" } ], "standard_charges": [ { "minimum": 87.4, "maximum": 546.25, "setting": "outpatient", "gross_charge": 546.25, "discounted_cash": 382.37, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 546.25, "10th_percentile": 546.25, "90th_percentile": 546.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 546.25, "10th_percentile": 546.25, "90th_percentile": 546.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 546.25, "10th_percentile": 546.25, "90th_percentile": 546.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 546.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $546.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 546.25, "10th_percentile": 546.25, "90th_percentile": 546.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $546.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 117.44, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 117.44, "10th_percentile": 117.44, "90th_percentile": 117.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 437.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 437.0, "10th_percentile": 437.0, "90th_percentile": 437.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 327.75, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 327.75, "10th_percentile": 327.75, "90th_percentile": 327.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 409.69, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 409.69, "10th_percentile": 409.69, "90th_percentile": 409.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 185.18, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 185.18, "10th_percentile": 185.18, "90th_percentile": 185.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 382.38, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 382.38, "10th_percentile": 382.38, "90th_percentile": 382.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 273.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 273.13, "10th_percentile": 273.13, "90th_percentile": 273.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 464.31, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 464.31, "10th_percentile": 464.31, "90th_percentile": 464.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 409.69, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 409.69, "10th_percentile": 409.69, "90th_percentile": 409.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 273.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 273.13, "10th_percentile": 273.13, "90th_percentile": 273.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 546.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 546.25, "10th_percentile": 546.25, "90th_percentile": 546.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 437.0, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 437.0, "10th_percentile": 437.0, "90th_percentile": 437.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 104.88, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 104.88, "10th_percentile": 104.88, "90th_percentile": 104.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 104.88, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 104.88, "10th_percentile": 104.88, "90th_percentile": 104.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 213.75, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 213.75, "10th_percentile": 213.75, "90th_percentile": 213.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 213.75, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 213.75, "10th_percentile": 213.75, "90th_percentile": 213.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 87.4, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 87.4, "10th_percentile": 87.4, "90th_percentile": 87.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 87.4, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 87.4, "10th_percentile": 87.4, "90th_percentile": 87.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 87.4, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 87.4, "10th_percentile": 87.4, "90th_percentile": 87.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 546.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 546.25, "10th_percentile": 546.25, "90th_percentile": 546.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 546.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 546.25, "10th_percentile": 546.25, "90th_percentile": 546.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 546.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 546.25, "10th_percentile": 546.25, "90th_percentile": 546.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 546.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 546.25, "10th_percentile": 546.25, "90th_percentile": 546.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 546.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 546.25, "10th_percentile": 546.25, "90th_percentile": 546.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 546.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 546.25, "10th_percentile": 546.25, "90th_percentile": 546.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 546.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 546.25, "10th_percentile": 546.25, "90th_percentile": 546.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 546.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 546.25, "10th_percentile": 546.25, "90th_percentile": 546.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BLADE BEAVER 75L (37-7515)", "code_information": [ { "code": "SUP-156803", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 2.52, "maximum": 18.03, "setting": "outpatient", "gross_charge": 18.03, "discounted_cash": 12.62, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3.05, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.05, "10th_percentile": 3.05, "90th_percentile": 3.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 7.98, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.98, "10th_percentile": 7.98, "90th_percentile": 7.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 7.06, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.06, "10th_percentile": 7.06, "90th_percentile": 7.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2.57, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.57, "10th_percentile": 2.57, "90th_percentile": 2.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 2.52, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.52, "10th_percentile": 2.52, "90th_percentile": 2.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 18.03, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $18.03 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 18.03, "10th_percentile": 18.03, "90th_percentile": 18.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $18.03 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 15.33, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 15.33, "10th_percentile": 15.33, "90th_percentile": 15.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 11.58, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 11.58, "10th_percentile": 11.58, "90th_percentile": 11.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 9.02, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 9.02, "10th_percentile": 9.02, "90th_percentile": 9.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 6.11, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 6.11, "10th_percentile": 6.11, "90th_percentile": 6.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 12.62, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 12.62, "10th_percentile": 12.62, "90th_percentile": 12.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 13.52, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 13.52, "10th_percentile": 13.52, "90th_percentile": 13.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 7.98, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.98, "10th_percentile": 7.98, "90th_percentile": 7.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 9.02, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.02, "10th_percentile": 9.02, "90th_percentile": 9.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 14.42, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 14.42, "10th_percentile": 14.42, "90th_percentile": 14.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 10.82, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 10.82, "10th_percentile": 10.82, "90th_percentile": 10.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 3.88, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 3.88, "10th_percentile": 3.88, "90th_percentile": 3.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 7.06, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.06, "10th_percentile": 7.06, "90th_percentile": 7.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 13.52, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 13.52, "10th_percentile": 13.52, "90th_percentile": 13.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 5.34, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.34, "10th_percentile": 5.34, "90th_percentile": 5.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 3.37, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.37, "10th_percentile": 3.37, "90th_percentile": 3.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 14.42, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.42, "10th_percentile": 14.42, "90th_percentile": 14.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 18.03, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 18.03, "10th_percentile": 18.03, "90th_percentile": 18.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 8.17, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.17, "10th_percentile": 8.17, "90th_percentile": 8.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 9.21, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.21, "10th_percentile": 9.21, "90th_percentile": 9.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 10.24, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.24, "10th_percentile": 10.24, "90th_percentile": 10.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 10.24, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.24, "10th_percentile": 10.24, "90th_percentile": 10.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 18.03, "10th_percentile": 18.03, "90th_percentile": 18.03, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 18.03, "10th_percentile": 18.03, "90th_percentile": 18.03, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 18.03, "10th_percentile": 18.03, "90th_percentile": 18.03, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 18.03, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 18.03, "10th_percentile": 18.03, "90th_percentile": 18.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 18.03, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 18.03, "10th_percentile": 18.03, "90th_percentile": 18.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 18.03, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 18.03, "10th_percentile": 18.03, "90th_percentile": 18.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 18.03, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 18.03, "10th_percentile": 18.03, "90th_percentile": 18.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 18.03, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 18.03, "10th_percentile": 18.03, "90th_percentile": 18.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 18.03, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 18.03, "10th_percentile": 18.03, "90th_percentile": 18.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 18.03, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 18.03, "10th_percentile": 18.03, "90th_percentile": 18.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 18.03, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 18.03, "10th_percentile": 18.03, "90th_percentile": 18.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BLADE CRVD 12MMX16CM LATERAL HIP SBLDCURVE-2", "code_information": [ { "code": "SUP-423529", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 56.96, "maximum": 407.15, "setting": "outpatient", "gross_charge": 407.15, "discounted_cash": 285.0, "payers_information": [ { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 231.26, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 231.26, "10th_percentile": 231.26, "90th_percentile": 231.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 305.36, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 305.36, "10th_percentile": 305.36, "90th_percentile": 305.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 285.01, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 285.01, "10th_percentile": 285.01, "90th_percentile": 285.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 305.36, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 305.36, "10th_percentile": 305.36, "90th_percentile": 305.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 203.58, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 203.58, "10th_percentile": 203.58, "90th_percentile": 203.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 244.29, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 244.29, "10th_percentile": 244.29, "90th_percentile": 244.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 261.51, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 261.51, "10th_percentile": 261.51, "90th_percentile": 261.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 346.08, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 346.08, "10th_percentile": 346.08, "90th_percentile": 346.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 184.44, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 184.44, "10th_percentile": 184.44, "90th_percentile": 184.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 208.05, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 208.05, "10th_percentile": 208.05, "90th_percentile": 208.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 407.15, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 407.15, "10th_percentile": 407.15, "90th_percentile": 407.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 325.72, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 325.72, "10th_percentile": 325.72, "90th_percentile": 325.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 120.52, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 120.52, "10th_percentile": 120.52, "90th_percentile": 120.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 407.15, "10th_percentile": 407.15, "90th_percentile": 407.15, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 407.15, "10th_percentile": 407.15, "90th_percentile": 407.15, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 407.15, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 407.15, "10th_percentile": 407.15, "90th_percentile": 407.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 407.15, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 407.15, "10th_percentile": 407.15, "90th_percentile": 407.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 407.15, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 407.15, "10th_percentile": 407.15, "90th_percentile": 407.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 407.15, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 407.15, "10th_percentile": 407.15, "90th_percentile": 407.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 407.15, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 407.15, "10th_percentile": 407.15, "90th_percentile": 407.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 407.15, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 407.15, "10th_percentile": 407.15, "90th_percentile": 407.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 407.15, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 407.15, "10th_percentile": 407.15, "90th_percentile": 407.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 68.93, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 68.93, "10th_percentile": 68.93, "90th_percentile": 68.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 180.29, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 180.29, "10th_percentile": 180.29, "90th_percentile": 180.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 159.32, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 159.32, "10th_percentile": 159.32, "90th_percentile": 159.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 58.1, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 58.1, "10th_percentile": 58.1, "90th_percentile": 58.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 56.96, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 56.96, "10th_percentile": 56.96, "90th_percentile": 56.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 407.15, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $407.15 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 407.15, "10th_percentile": 407.15, "90th_percentile": 407.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $407.15 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 138.02, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 138.02, "10th_percentile": 138.02, "90th_percentile": 138.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 180.29, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 180.29, "10th_percentile": 180.29, "90th_percentile": 180.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 203.58, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 203.58, "10th_percentile": 203.58, "90th_percentile": 203.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 325.72, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 325.72, "10th_percentile": 325.72, "90th_percentile": 325.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 87.54, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 87.54, "10th_percentile": 87.54, "90th_percentile": 87.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 159.32, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 159.32, "10th_percentile": 159.32, "90th_percentile": 159.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 76.14, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 76.14, "10th_percentile": 76.14, "90th_percentile": 76.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 231.26, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 231.26, "10th_percentile": 231.26, "90th_percentile": 231.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 407.15, "10th_percentile": 407.15, "90th_percentile": 407.15, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 407.15, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 407.15, "10th_percentile": 407.15, "90th_percentile": 407.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BLADE GLIDESCOPE TITANIUM SPECTRUM LOPRO S3 0270-0938", "code_information": [ { "code": "SUP-341029", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 12.46, "maximum": 89.09, "setting": "outpatient", "gross_charge": 89.09, "discounted_cash": 62.36, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 34.86, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 34.86, "10th_percentile": 34.86, "90th_percentile": 34.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 15.08, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15.08, "10th_percentile": 15.08, "90th_percentile": 15.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 12.71, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.71, "10th_percentile": 12.71, "90th_percentile": 12.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 12.46, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.46, "10th_percentile": 12.46, "90th_percentile": 12.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 89.09, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $89.09 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 89.09, "10th_percentile": 89.09, "90th_percentile": 89.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $89.09 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 30.2, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 30.2, "10th_percentile": 30.2, "90th_percentile": 30.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 19.15, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 19.15, "10th_percentile": 19.15, "90th_percentile": 19.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 34.86, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 34.86, "10th_percentile": 34.86, "90th_percentile": 34.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 39.45, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.45, "10th_percentile": 39.45, "90th_percentile": 39.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 71.27, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 71.27, "10th_percentile": 71.27, "90th_percentile": 71.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 50.6, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 50.6, "10th_percentile": 50.6, "90th_percentile": 50.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 89.09, "10th_percentile": 89.09, "90th_percentile": 89.09, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 89.09, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 89.09, "10th_percentile": 89.09, "90th_percentile": 89.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 39.45, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.45, "10th_percentile": 39.45, "90th_percentile": 39.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 75.73, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 75.73, "10th_percentile": 75.73, "90th_percentile": 75.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 57.22, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 57.22, "10th_percentile": 57.22, "90th_percentile": 57.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 44.55, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 44.55, "10th_percentile": 44.55, "90th_percentile": 44.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 62.36, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 62.36, "10th_percentile": 62.36, "90th_percentile": 62.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 66.82, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 66.82, "10th_percentile": 66.82, "90th_percentile": 66.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 44.55, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 44.55, "10th_percentile": 44.55, "90th_percentile": 44.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 53.45, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 53.45, "10th_percentile": 53.45, "90th_percentile": 53.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 66.82, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 66.82, "10th_percentile": 66.82, "90th_percentile": 66.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 26.37, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 26.37, "10th_percentile": 26.37, "90th_percentile": 26.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 16.66, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.66, "10th_percentile": 16.66, "90th_percentile": 16.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 71.27, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 71.27, "10th_percentile": 71.27, "90th_percentile": 71.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 89.09, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 89.09, "10th_percentile": 89.09, "90th_percentile": 89.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 40.36, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 40.36, "10th_percentile": 40.36, "90th_percentile": 40.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 45.52, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 45.52, "10th_percentile": 45.52, "90th_percentile": 45.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 50.6, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 50.6, "10th_percentile": 50.6, "90th_percentile": 50.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 89.09, "10th_percentile": 89.09, "90th_percentile": 89.09, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 89.09, "10th_percentile": 89.09, "90th_percentile": 89.09, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 89.09, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 89.09, "10th_percentile": 89.09, "90th_percentile": 89.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 89.09, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 89.09, "10th_percentile": 89.09, "90th_percentile": 89.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 89.09, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 89.09, "10th_percentile": 89.09, "90th_percentile": 89.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 89.09, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 89.09, "10th_percentile": 89.09, "90th_percentile": 89.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 89.09, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 89.09, "10th_percentile": 89.09, "90th_percentile": 89.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 89.09, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 89.09, "10th_percentile": 89.09, "90th_percentile": 89.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 89.09, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 89.09, "10th_percentile": 89.09, "90th_percentile": 89.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BLADE LIGHTED RETRACTOR BRITEFIELD WAVEGUDE 104015", "code_information": [ { "code": "SUP-353169", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 92.14, "maximum": 658.63, "setting": "outpatient", "gross_charge": 658.63, "discounted_cash": 461.04, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 257.72, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 257.72, "10th_percentile": 257.72, "90th_percentile": 257.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 257.72, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 257.72, "10th_percentile": 257.72, "90th_percentile": 257.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 291.64, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 291.64, "10th_percentile": 291.64, "90th_percentile": 291.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 291.64, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 291.64, "10th_percentile": 291.64, "90th_percentile": 291.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 374.1, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 374.1, "10th_percentile": 374.1, "90th_percentile": 374.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 374.1, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 374.1, "10th_percentile": 374.1, "90th_percentile": 374.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 493.97, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 493.97, "10th_percentile": 493.97, "90th_percentile": 493.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 141.61, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 141.61, "10th_percentile": 141.61, "90th_percentile": 141.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 223.28, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 223.28, "10th_percentile": 223.28, "90th_percentile": 223.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 461.04, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 461.04, "10th_percentile": 461.04, "90th_percentile": 461.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 493.97, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 493.97, "10th_percentile": 493.97, "90th_percentile": 493.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 329.32, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 329.32, "10th_percentile": 329.32, "90th_percentile": 329.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 329.32, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 329.32, "10th_percentile": 329.32, "90th_percentile": 329.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 526.9, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 526.9, "10th_percentile": 526.9, "90th_percentile": 526.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 395.18, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 395.18, "10th_percentile": 395.18, "90th_percentile": 395.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 423.04, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 423.04, "10th_percentile": 423.04, "90th_percentile": 423.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 559.84, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 559.84, "10th_percentile": 559.84, "90th_percentile": 559.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 298.36, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 298.36, "10th_percentile": 298.36, "90th_percentile": 298.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 336.56, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 336.56, "10th_percentile": 336.56, "90th_percentile": 336.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 658.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 658.63, "10th_percentile": 658.63, "90th_percentile": 658.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 123.16, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 123.16, "10th_percentile": 123.16, "90th_percentile": 123.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 526.9, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 526.9, "10th_percentile": 526.9, "90th_percentile": 526.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 194.95, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 194.95, "10th_percentile": 194.95, "90th_percentile": 194.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 658.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $658.63 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 658.63, "10th_percentile": 658.63, "90th_percentile": 658.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $658.63 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 111.51, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 111.51, "10th_percentile": 111.51, "90th_percentile": 111.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 92.14, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 92.14, "10th_percentile": 92.14, "90th_percentile": 92.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 93.99, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 93.99, "10th_percentile": 93.99, "90th_percentile": 93.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 658.63, "10th_percentile": 658.63, "90th_percentile": 658.63, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 658.63, "10th_percentile": 658.63, "90th_percentile": 658.63, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 658.63, "10th_percentile": 658.63, "90th_percentile": 658.63, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 658.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 658.63, "10th_percentile": 658.63, "90th_percentile": 658.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 658.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 658.63, "10th_percentile": 658.63, "90th_percentile": 658.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 658.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 658.63, "10th_percentile": 658.63, "90th_percentile": 658.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 658.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 658.63, "10th_percentile": 658.63, "90th_percentile": 658.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 658.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 658.63, "10th_percentile": 658.63, "90th_percentile": 658.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 658.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 658.63, "10th_percentile": 658.63, "90th_percentile": 658.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 658.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 658.63, "10th_percentile": 658.63, "90th_percentile": 658.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 658.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 658.63, "10th_percentile": 658.63, "90th_percentile": 658.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BLADE REAMER PATELLA WITH PILOT HOLE 46MM DIA", "code_information": [ { "code": "SUP-378524", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 46.91, "maximum": 335.3, "setting": "outpatient", "gross_charge": 335.3, "discounted_cash": 234.71, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 131.2, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 131.2, "10th_percentile": 131.2, "90th_percentile": 131.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 131.2, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 131.2, "10th_percentile": 131.2, "90th_percentile": 131.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 148.47, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 148.47, "10th_percentile": 148.47, "90th_percentile": 148.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 148.47, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 148.47, "10th_percentile": 148.47, "90th_percentile": 148.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 190.45, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 190.45, "10th_percentile": 190.45, "90th_percentile": 190.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 190.45, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 190.45, "10th_percentile": 190.45, "90th_percentile": 190.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 251.48, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 251.48, "10th_percentile": 251.48, "90th_percentile": 251.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 72.09, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 72.09, "10th_percentile": 72.09, "90th_percentile": 72.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 113.67, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 113.67, "10th_percentile": 113.67, "90th_percentile": 113.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 234.71, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 234.71, "10th_percentile": 234.71, "90th_percentile": 234.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 251.48, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 251.48, "10th_percentile": 251.48, "90th_percentile": 251.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 167.65, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 167.65, "10th_percentile": 167.65, "90th_percentile": 167.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 167.65, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 167.65, "10th_percentile": 167.65, "90th_percentile": 167.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 268.24, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 268.24, "10th_percentile": 268.24, "90th_percentile": 268.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 201.18, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 201.18, "10th_percentile": 201.18, "90th_percentile": 201.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 215.36, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 215.36, "10th_percentile": 215.36, "90th_percentile": 215.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 285.01, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 285.01, "10th_percentile": 285.01, "90th_percentile": 285.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 151.89, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 151.89, "10th_percentile": 151.89, "90th_percentile": 151.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 171.34, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 171.34, "10th_percentile": 171.34, "90th_percentile": 171.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 335.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 335.3, "10th_percentile": 335.3, "90th_percentile": 335.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 62.7, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 62.7, "10th_percentile": 62.7, "90th_percentile": 62.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 268.24, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 268.24, "10th_percentile": 268.24, "90th_percentile": 268.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 99.25, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 99.25, "10th_percentile": 99.25, "90th_percentile": 99.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 335.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $335.30 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 335.3, "10th_percentile": 335.3, "90th_percentile": 335.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $335.30 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 56.77, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 56.77, "10th_percentile": 56.77, "90th_percentile": 56.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 46.91, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 46.91, "10th_percentile": 46.91, "90th_percentile": 46.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 47.85, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 47.85, "10th_percentile": 47.85, "90th_percentile": 47.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 335.3, "10th_percentile": 335.3, "90th_percentile": 335.3, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 335.3, "10th_percentile": 335.3, "90th_percentile": 335.3, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 335.3, "10th_percentile": 335.3, "90th_percentile": 335.3, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 335.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 335.3, "10th_percentile": 335.3, "90th_percentile": 335.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 335.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 335.3, "10th_percentile": 335.3, "90th_percentile": 335.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 335.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 335.3, "10th_percentile": 335.3, "90th_percentile": 335.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 335.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 335.3, "10th_percentile": 335.3, "90th_percentile": 335.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 335.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 335.3, "10th_percentile": 335.3, "90th_percentile": 335.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 335.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 335.3, "10th_percentile": 335.3, "90th_percentile": 335.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 335.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 335.3, "10th_percentile": 335.3, "90th_percentile": 335.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 335.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 335.3, "10th_percentile": 335.3, "90th_percentile": 335.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BLADE SW 90X19.5X1.27MM INTREX", "code_information": [ { "code": "SUP-394016", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 61.0, "maximum": 436.01, "setting": "outpatient", "gross_charge": 436.01, "discounted_cash": 305.21, "payers_information": [ { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 247.65, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 247.65, "10th_percentile": 247.65, "90th_percentile": 247.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 327.01, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 327.01, "10th_percentile": 327.01, "90th_percentile": 327.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 305.21, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 305.21, "10th_percentile": 305.21, "90th_percentile": 305.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 327.01, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 327.01, "10th_percentile": 327.01, "90th_percentile": 327.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 218.01, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 218.01, "10th_percentile": 218.01, "90th_percentile": 218.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 218.01, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 218.01, "10th_percentile": 218.01, "90th_percentile": 218.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 261.61, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 261.61, "10th_percentile": 261.61, "90th_percentile": 261.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 280.05, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 280.05, "10th_percentile": 280.05, "90th_percentile": 280.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 370.61, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 370.61, "10th_percentile": 370.61, "90th_percentile": 370.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 197.51, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 197.51, "10th_percentile": 197.51, "90th_percentile": 197.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 222.8, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 222.8, "10th_percentile": 222.8, "90th_percentile": 222.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 436.01, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 436.01, "10th_percentile": 436.01, "90th_percentile": 436.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 81.53, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 81.53, "10th_percentile": 81.53, "90th_percentile": 81.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 348.81, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 348.81, "10th_percentile": 348.81, "90th_percentile": 348.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 129.06, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 129.06, "10th_percentile": 129.06, "90th_percentile": 129.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 436.01, "10th_percentile": 436.01, "90th_percentile": 436.01, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 436.01, "10th_percentile": 436.01, "90th_percentile": 436.01, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 436.01, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 436.01, "10th_percentile": 436.01, "90th_percentile": 436.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 436.01, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 436.01, "10th_percentile": 436.01, "90th_percentile": 436.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 436.01, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 436.01, "10th_percentile": 436.01, "90th_percentile": 436.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 436.01, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 436.01, "10th_percentile": 436.01, "90th_percentile": 436.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 436.01, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 436.01, "10th_percentile": 436.01, "90th_percentile": 436.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 436.01, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 436.01, "10th_percentile": 436.01, "90th_percentile": 436.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 436.01, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 436.01, "10th_percentile": 436.01, "90th_percentile": 436.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 170.61, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 170.61, "10th_percentile": 170.61, "90th_percentile": 170.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 73.82, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 73.82, "10th_percentile": 73.82, "90th_percentile": 73.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 62.22, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 62.22, "10th_percentile": 62.22, "90th_percentile": 62.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 61.0, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 61.0, "10th_percentile": 61.0, "90th_percentile": 61.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 193.07, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 193.07, "10th_percentile": 193.07, "90th_percentile": 193.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 436.01, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $436.01 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 436.01, "10th_percentile": 436.01, "90th_percentile": 436.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $436.01 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 147.81, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 147.81, "10th_percentile": 147.81, "90th_percentile": 147.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 93.74, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 93.74, "10th_percentile": 93.74, "90th_percentile": 93.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 170.61, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 170.61, "10th_percentile": 170.61, "90th_percentile": 170.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 193.07, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 193.07, "10th_percentile": 193.07, "90th_percentile": 193.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 348.81, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 348.81, "10th_percentile": 348.81, "90th_percentile": 348.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 247.65, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 247.65, "10th_percentile": 247.65, "90th_percentile": 247.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 436.01, "10th_percentile": 436.01, "90th_percentile": 436.01, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 436.01, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 436.01, "10th_percentile": 436.01, "90th_percentile": 436.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BLANKET INTOP UPPR BDY BAIR HGGR MUL-POSITION 78X24IN", "code_information": [ { "code": "SUP-337798", "type": "CDM" }, { "code": "27103350", "type": "LOCAL" }, { "code": "0271", "type": "RC" } ], "standard_charges": [ { "minimum": 2.08, "maximum": 14.85, "setting": "outpatient", "gross_charge": 14.85, "discounted_cash": 10.39, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 14.85, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 14.85, "10th_percentile": 14.85, "90th_percentile": 14.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 14.85, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 14.85, "10th_percentile": 14.85, "90th_percentile": 14.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 14.85, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 14.85, "10th_percentile": 14.85, "90th_percentile": 14.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 14.85, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 14.85, "10th_percentile": 14.85, "90th_percentile": 14.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 14.85, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 14.85, "10th_percentile": 14.85, "90th_percentile": 14.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 14.85, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 14.85, "10th_percentile": 14.85, "90th_percentile": 14.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 14.85, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 14.85, "10th_percentile": 14.85, "90th_percentile": 14.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 14.85, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 14.85, "10th_percentile": 14.85, "90th_percentile": 14.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 5.03, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 5.03, "10th_percentile": 5.03, "90th_percentile": 5.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 3.19, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 3.19, "10th_percentile": 3.19, "90th_percentile": 3.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 2.78, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.78, "10th_percentile": 2.78, "90th_percentile": 2.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 11.88, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 11.88, "10th_percentile": 11.88, "90th_percentile": 11.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 7.43, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 7.43, "10th_percentile": 7.43, "90th_percentile": 7.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 10.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 10.4, "10th_percentile": 10.4, "90th_percentile": 10.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 7.43, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.43, "10th_percentile": 7.43, "90th_percentile": 7.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 11.88, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.88, "10th_percentile": 11.88, "90th_percentile": 11.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 4.4, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.4, "10th_percentile": 4.4, "90th_percentile": 4.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 11.14, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 11.14, "10th_percentile": 11.14, "90th_percentile": 11.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 11.14, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 11.14, "10th_percentile": 11.14, "90th_percentile": 11.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 9.54, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 9.54, "10th_percentile": 9.54, "90th_percentile": 9.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 8.91, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 8.91, "10th_percentile": 8.91, "90th_percentile": 8.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 12.62, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 12.62, "10th_percentile": 12.62, "90th_percentile": 12.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 7.59, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.59, "10th_percentile": 7.59, "90th_percentile": 7.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 6.73, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.73, "10th_percentile": 6.73, "90th_percentile": 6.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 14.85, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 14.85, "10th_percentile": 14.85, "90th_percentile": 14.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 14.85, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $14.85 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 14.85, "10th_percentile": 14.85, "90th_percentile": 14.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $14.85 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2.12, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.12, "10th_percentile": 2.12, "90th_percentile": 2.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 2.08, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.08, "10th_percentile": 2.08, "90th_percentile": 2.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2.51, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.51, "10th_percentile": 2.51, "90th_percentile": 2.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 6.58, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.58, "10th_percentile": 6.58, "90th_percentile": 6.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 6.58, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.58, "10th_percentile": 6.58, "90th_percentile": 6.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 8.43, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.43, "10th_percentile": 8.43, "90th_percentile": 8.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 8.43, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.43, "10th_percentile": 8.43, "90th_percentile": 8.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 5.81, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.81, "10th_percentile": 5.81, "90th_percentile": 5.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 5.81, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.81, "10th_percentile": 5.81, "90th_percentile": 5.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 14.85, "10th_percentile": 14.85, "90th_percentile": 14.85, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 14.85, "10th_percentile": 14.85, "90th_percentile": 14.85, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 14.85, "10th_percentile": 14.85, "90th_percentile": 14.85, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "BLDE HEL CANN 11X100MM TI STRL", "code_information": [ { "code": "SUP-3054", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 209.27, "maximum": 1307.95, "setting": "outpatient", "gross_charge": 1307.95, "discounted_cash": 915.56, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 668.36, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 252.68, "10th_percentile": 252.68, "90th_percentile": 252.68, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 281.21, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 373.87, "10th_percentile": 373.87, "90th_percentile": 373.87, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 209.27, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 209.27, "10th_percentile": 209.27, "90th_percentile": 209.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 209.27, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 209.27, "10th_percentile": 209.27, "90th_percentile": 209.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 209.27, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 209.27, "10th_percentile": 209.27, "90th_percentile": 209.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 251.13, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 251.13, "10th_percentile": 251.13, "90th_percentile": 251.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 251.13, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 251.13, "10th_percentile": 251.13, "90th_percentile": 251.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 742.92, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 742.92, "10th_percentile": 742.92, "90th_percentile": 742.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 742.92, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 742.92, "10th_percentile": 742.92, "90th_percentile": 742.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 511.8, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 511.8, "10th_percentile": 511.8, "90th_percentile": 511.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 511.8, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 511.8, "10th_percentile": 511.8, "90th_percentile": 511.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 387.15, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.51, "10th_percentile": 5.51, "90th_percentile": 5.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 980.96, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 980.96, "10th_percentile": 980.96, "90th_percentile": 980.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1046.36, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1046.36, "10th_percentile": 1046.36, "90th_percentile": 1046.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 840.1, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 840.1, "10th_percentile": 840.1, "90th_percentile": 840.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1307.95, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,307.95 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1307.95, "10th_percentile": 1307.95, "90th_percentile": 1307.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,307.95 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 653.98, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 653.98, "10th_percentile": 653.98, "90th_percentile": 653.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1046.36, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1046.36, "10th_percentile": 1046.36, "90th_percentile": 1046.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 592.5, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 592.5, "10th_percentile": 592.5, "90th_percentile": 592.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 653.98, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 653.98, "10th_percentile": 653.98, "90th_percentile": 653.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1111.76, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1111.76, "10th_percentile": 1111.76, "90th_percentile": 1111.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 915.57, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 915.57, "10th_percentile": 915.57, "90th_percentile": 915.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 443.4, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 443.4, "10th_percentile": 443.4, "90th_percentile": 443.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1307.95, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1307.95, "10th_percentile": 1307.95, "90th_percentile": 1307.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 784.77, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 784.77, "10th_percentile": 784.77, "90th_percentile": 784.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 980.96, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 980.96, "10th_percentile": 980.96, "90th_percentile": 980.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 244.59, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 244.59, "10th_percentile": 244.59, "90th_percentile": 244.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1307.95, "10th_percentile": 1307.95, "90th_percentile": 1307.95, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1307.95, "10th_percentile": 1307.95, "90th_percentile": 1307.95, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1307.95, "10th_percentile": 1307.95, "90th_percentile": 1307.95, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1307.95, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1307.95, "10th_percentile": 1307.95, "90th_percentile": 1307.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1307.95, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1307.95, "10th_percentile": 1307.95, "90th_percentile": 1307.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1307.95, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1307.95, "10th_percentile": 1307.95, "90th_percentile": 1307.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1307.95, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1307.95, "10th_percentile": 1307.95, "90th_percentile": 1307.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1307.95, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1307.95, "10th_percentile": 1307.95, "90th_percentile": 1307.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1307.95, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1307.95, "10th_percentile": 1307.95, "90th_percentile": 1307.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1307.95, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1307.95, "10th_percentile": 1307.95, "90th_percentile": 1307.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1307.95, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1307.95, "10th_percentile": 1307.95, "90th_percentile": 1307.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BLDE NL FEM RG NL-EX 100MM TI SPRL STRL", "code_information": [ { "code": "SUP-37410", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 182.62, "maximum": 1141.39, "setting": "outpatient", "gross_charge": 1141.39, "discounted_cash": 798.97, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 245.4, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 373.87, "10th_percentile": 373.87, "90th_percentile": 373.87, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 182.62, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 182.62, "10th_percentile": 182.62, "90th_percentile": 182.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 182.62, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 182.62, "10th_percentile": 182.62, "90th_percentile": 182.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 182.62, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 182.62, "10th_percentile": 182.62, "90th_percentile": 182.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 648.31, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 648.31, "10th_percentile": 648.31, "90th_percentile": 648.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 219.15, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 219.15, "10th_percentile": 219.15, "90th_percentile": 219.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 219.15, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 219.15, "10th_percentile": 219.15, "90th_percentile": 219.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 446.63, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 446.63, "10th_percentile": 446.63, "90th_percentile": 446.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 446.63, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 446.63, "10th_percentile": 446.63, "90th_percentile": 446.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 570.7, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 570.7, "10th_percentile": 570.7, "90th_percentile": 570.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 913.11, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 913.11, "10th_percentile": 913.11, "90th_percentile": 913.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1141.39, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,141.39 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1141.39, "10th_percentile": 1141.39, "90th_percentile": 1141.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,141.39 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 913.11, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 913.11, "10th_percentile": 913.11, "90th_percentile": 913.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 213.44, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 213.44, "10th_percentile": 213.44, "90th_percentile": 213.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 386.93, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 386.93, "10th_percentile": 386.93, "90th_percentile": 386.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1141.39, "10th_percentile": 1141.39, "90th_percentile": 1141.39, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1141.39, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1141.39, "10th_percentile": 1141.39, "90th_percentile": 1141.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 583.25, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 252.68, "10th_percentile": 252.68, "90th_percentile": 252.68, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 648.31, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 648.31, "10th_percentile": 648.31, "90th_percentile": 648.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 337.85, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.51, "10th_percentile": 5.51, "90th_percentile": 5.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 798.97, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 798.97, "10th_percentile": 798.97, "90th_percentile": 798.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 570.7, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 570.7, "10th_percentile": 570.7, "90th_percentile": 570.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1141.39, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1141.39, "10th_percentile": 1141.39, "90th_percentile": 1141.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 856.04, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 856.04, "10th_percentile": 856.04, "90th_percentile": 856.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 684.83, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 684.83, "10th_percentile": 684.83, "90th_percentile": 684.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 856.04, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 856.04, "10th_percentile": 856.04, "90th_percentile": 856.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 733.11, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 733.11, "10th_percentile": 733.11, "90th_percentile": 733.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 517.05, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 517.05, "10th_percentile": 517.05, "90th_percentile": 517.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 970.18, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 970.18, "10th_percentile": 970.18, "90th_percentile": 970.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1141.39, "10th_percentile": 1141.39, "90th_percentile": 1141.39, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1141.39, "10th_percentile": 1141.39, "90th_percentile": 1141.39, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1141.39, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1141.39, "10th_percentile": 1141.39, "90th_percentile": 1141.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1141.39, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1141.39, "10th_percentile": 1141.39, "90th_percentile": 1141.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1141.39, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1141.39, "10th_percentile": 1141.39, "90th_percentile": 1141.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1141.39, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1141.39, "10th_percentile": 1141.39, "90th_percentile": 1141.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1141.39, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1141.39, "10th_percentile": 1141.39, "90th_percentile": 1141.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1141.39, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1141.39, "10th_percentile": 1141.39, "90th_percentile": 1141.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1141.39, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1141.39, "10th_percentile": 1141.39, "90th_percentile": 1141.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BLDE OSTEOTOM BNE THN 8MMX3IN", "code_information": [ { "code": "SUP-144464", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 103.87, "maximum": 742.45, "setting": "outpatient", "gross_charge": 742.45, "discounted_cash": 519.71, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 290.52, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 290.52, "10th_percentile": 290.52, "90th_percentile": 290.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 125.7, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 125.7, "10th_percentile": 125.7, "90th_percentile": 125.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 105.95, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 105.95, "10th_percentile": 105.95, "90th_percentile": 105.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 103.87, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 103.87, "10th_percentile": 103.87, "90th_percentile": 103.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 328.76, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 328.76, "10th_percentile": 328.76, "90th_percentile": 328.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 742.45, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $742.45 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 742.45, "10th_percentile": 742.45, "90th_percentile": 742.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $742.45 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 251.69, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 251.69, "10th_percentile": 251.69, "90th_percentile": 251.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 159.63, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 159.63, "10th_percentile": 159.63, "90th_percentile": 159.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 556.84, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 556.84, "10th_percentile": 556.84, "90th_percentile": 556.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 556.84, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 556.84, "10th_percentile": 556.84, "90th_percentile": 556.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 290.52, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 290.52, "10th_percentile": 290.52, "90th_percentile": 290.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 631.08, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 631.08, "10th_percentile": 631.08, "90th_percentile": 631.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 519.72, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 519.72, "10th_percentile": 519.72, "90th_percentile": 519.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 371.23, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 371.23, "10th_percentile": 371.23, "90th_percentile": 371.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 371.23, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 371.23, "10th_percentile": 371.23, "90th_percentile": 371.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 445.47, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 445.47, "10th_percentile": 445.47, "90th_percentile": 445.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 328.76, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 328.76, "10th_percentile": 328.76, "90th_percentile": 328.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 593.96, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 593.96, "10th_percentile": 593.96, "90th_percentile": 593.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 138.84, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 138.84, "10th_percentile": 138.84, "90th_percentile": 138.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 219.77, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 219.77, "10th_percentile": 219.77, "90th_percentile": 219.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 593.96, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 593.96, "10th_percentile": 593.96, "90th_percentile": 593.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 421.71, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 421.71, "10th_percentile": 421.71, "90th_percentile": 421.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 421.71, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 421.71, "10th_percentile": 421.71, "90th_percentile": 421.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 742.45, "10th_percentile": 742.45, "90th_percentile": 742.45, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 742.45, "10th_percentile": 742.45, "90th_percentile": 742.45, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 742.45, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 742.45, "10th_percentile": 742.45, "90th_percentile": 742.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 742.45, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 742.45, "10th_percentile": 742.45, "90th_percentile": 742.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 742.45, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 742.45, "10th_percentile": 742.45, "90th_percentile": 742.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 742.45, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 742.45, "10th_percentile": 742.45, "90th_percentile": 742.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 742.45, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 742.45, "10th_percentile": 742.45, "90th_percentile": 742.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 742.45, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 742.45, "10th_percentile": 742.45, "90th_percentile": 742.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 742.45, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 742.45, "10th_percentile": 742.45, "90th_percentile": 742.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 476.88, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 476.88, "10th_percentile": 476.88, "90th_percentile": 476.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 336.33, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 336.33, "10th_percentile": 336.33, "90th_percentile": 336.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 379.39, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 379.39, "10th_percentile": 379.39, "90th_percentile": 379.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 742.45, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 742.45, "10th_percentile": 742.45, "90th_percentile": 742.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 742.45, "10th_percentile": 742.45, "90th_percentile": 742.45, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 742.45, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 742.45, "10th_percentile": 742.45, "90th_percentile": 742.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BLN ENDOSCOPIC URETERAL OCCLUSION 34 FR 65 CM LENGTH OBLONG", "code_information": [ { "code": "SUP-392489", "type": "CDM" }, { "code": "C2628", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 53.17, "maximum": 332.31, "setting": "outpatient", "gross_charge": 332.31, "discounted_cash": 232.62, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 332.31, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 332.31, "10th_percentile": 332.31, "90th_percentile": 332.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 332.31, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 332.31, "10th_percentile": 332.31, "90th_percentile": 332.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 332.31, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 332.31, "10th_percentile": 332.31, "90th_percentile": 332.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 332.31, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 332.31, "10th_percentile": 332.31, "90th_percentile": 332.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 332.31, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 332.31, "10th_percentile": 332.31, "90th_percentile": 332.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 332.31, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 332.31, "10th_percentile": 332.31, "90th_percentile": 332.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 332.31, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 332.31, "10th_percentile": 332.31, "90th_percentile": 332.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 332.31, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 332.31, "10th_percentile": 332.31, "90th_percentile": 332.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 188.75, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 188.75, "10th_percentile": 188.75, "90th_percentile": 188.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 112.65, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 112.65, "10th_percentile": 112.65, "90th_percentile": 112.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 71.45, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 71.45, "10th_percentile": 71.45, "90th_percentile": 71.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 130.03, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 130.03, "10th_percentile": 130.03, "90th_percentile": 130.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 63.8, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 63.8, "10th_percentile": 63.8, "90th_percentile": 63.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 265.85, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 265.85, "10th_percentile": 265.85, "90th_percentile": 265.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 130.03, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 130.03, "10th_percentile": 130.03, "90th_percentile": 130.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 332.31, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $332.31 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 332.31, "10th_percentile": 332.31, "90th_percentile": 332.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $332.31 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 63.8, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 63.8, "10th_percentile": 63.8, "90th_percentile": 63.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 166.16, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 166.16, "10th_percentile": 166.16, "90th_percentile": 166.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 62.14, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 62.14, "10th_percentile": 62.14, "90th_percentile": 62.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 265.85, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 265.85, "10th_percentile": 265.85, "90th_percentile": 265.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 98.36, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 98.36, "10th_percentile": 98.36, "90th_percentile": 98.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 249.23, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 249.23, "10th_percentile": 249.23, "90th_percentile": 249.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 188.75, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 188.75, "10th_percentile": 188.75, "90th_percentile": 188.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 249.23, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 249.23, "10th_percentile": 249.23, "90th_percentile": 249.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 282.46, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 282.46, "10th_percentile": 282.46, "90th_percentile": 282.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 166.16, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 166.16, "10th_percentile": 166.16, "90th_percentile": 166.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 199.39, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 199.39, "10th_percentile": 199.39, "90th_percentile": 199.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 232.62, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 232.62, "10th_percentile": 232.62, "90th_percentile": 232.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 213.44, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 213.44, "10th_percentile": 213.44, "90th_percentile": 213.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 169.81, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 169.81, "10th_percentile": 169.81, "90th_percentile": 169.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 150.54, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 150.54, "10th_percentile": 150.54, "90th_percentile": 150.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 332.31, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 332.31, "10th_percentile": 332.31, "90th_percentile": 332.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 53.17, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 53.17, "10th_percentile": 53.17, "90th_percentile": 53.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 53.17, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 53.17, "10th_percentile": 53.17, "90th_percentile": 53.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 53.17, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 53.17, "10th_percentile": 53.17, "90th_percentile": 53.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 332.31, "10th_percentile": 332.31, "90th_percentile": 332.31, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 332.31, "10th_percentile": 332.31, "90th_percentile": 332.31, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 332.31, "10th_percentile": 332.31, "90th_percentile": 332.31, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "BODY FEM MOD REST STD +20X25MM CONE W/BOLT", "code_information": [ { "code": "SUP-114175", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 1528.16, "maximum": 9551.0, "setting": "outpatient", "gross_charge": 9551.0, "discounted_cash": 6685.7, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 4880.56, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2248.51, "10th_percentile": 2248.51, "90th_percentile": 2248.51, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 1528.16, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1528.16, "10th_percentile": 1528.16, "90th_percentile": 1528.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1528.16, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1528.16, "10th_percentile": 1528.16, "90th_percentile": 1528.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1528.16, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1528.16, "10th_percentile": 1528.16, "90th_percentile": 1528.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 5424.97, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5424.97, "10th_percentile": 5424.97, "90th_percentile": 5424.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 5424.97, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5424.97, "10th_percentile": 5424.97, "90th_percentile": 5424.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 9551.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $9,551.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 9551.0, "10th_percentile": 9551.0, "90th_percentile": 9551.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $9,551.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 2827.1, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2827.1, "10th_percentile": 2827.1, "90th_percentile": 2827.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 9551.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 9551.0, "10th_percentile": 9551.0, "90th_percentile": 9551.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 7163.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 7163.25, "10th_percentile": 7163.25, "90th_percentile": 7163.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 3237.79, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 3237.79, "10th_percentile": 3237.79, "90th_percentile": 3237.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 7640.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7640.8, "10th_percentile": 7640.8, "90th_percentile": 7640.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 7163.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 7163.25, "10th_percentile": 7163.25, "90th_percentile": 7163.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 2053.47, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 2053.47, "10th_percentile": 2053.47, "90th_percentile": 2053.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 6134.61, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 6134.61, "10th_percentile": 6134.61, "90th_percentile": 6134.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 4775.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4775.5, "10th_percentile": 4775.5, "90th_percentile": 4775.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 7640.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 7640.8, "10th_percentile": 7640.8, "90th_percentile": 7640.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 4326.6, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4326.6, "10th_percentile": 4326.6, "90th_percentile": 4326.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 6685.7, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 6685.7, "10th_percentile": 6685.7, "90th_percentile": 6685.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 5730.6, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 5730.6, "10th_percentile": 5730.6, "90th_percentile": 5730.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 8118.35, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 8118.35, "10th_percentile": 8118.35, "90th_percentile": 8118.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 4775.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 4775.5, "10th_percentile": 4775.5, "90th_percentile": 4775.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 1786.04, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1786.04, "10th_percentile": 1786.04, "90th_percentile": 1786.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 3737.31, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3737.31, "10th_percentile": 3737.31, "90th_percentile": 3737.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 3737.31, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3737.31, "10th_percentile": 3737.31, "90th_percentile": 3737.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1833.79, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1833.79, "10th_percentile": 1833.79, "90th_percentile": 1833.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1833.79, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1833.79, "10th_percentile": 1833.79, "90th_percentile": 1833.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 9551.0, "10th_percentile": 9551.0, "90th_percentile": 9551.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9551.0, "10th_percentile": 9551.0, "90th_percentile": 9551.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9551.0, "10th_percentile": 9551.0, "90th_percentile": 9551.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9551.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9551.0, "10th_percentile": 9551.0, "90th_percentile": 9551.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9551.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9551.0, "10th_percentile": 9551.0, "90th_percentile": 9551.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9551.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9551.0, "10th_percentile": 9551.0, "90th_percentile": 9551.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9551.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9551.0, "10th_percentile": 9551.0, "90th_percentile": 9551.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9551.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9551.0, "10th_percentile": 9551.0, "90th_percentile": 9551.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9551.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9551.0, "10th_percentile": 9551.0, "90th_percentile": 9551.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9551.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9551.0, "10th_percentile": 9551.0, "90th_percentile": 9551.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9551.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9551.0, "10th_percentile": 9551.0, "90th_percentile": 9551.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BODY FEM MOD REST STD +30X23MM CONE W/BOLT", "code_information": [ { "code": "SUP-106542", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 1528.16, "maximum": 9551.0, "setting": "outpatient", "gross_charge": 9551.0, "discounted_cash": 6685.7, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 4880.56, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2248.51, "10th_percentile": 2248.51, "90th_percentile": 2248.51, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1528.16, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1528.16, "10th_percentile": 1528.16, "90th_percentile": 1528.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 1528.16, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1528.16, "10th_percentile": 1528.16, "90th_percentile": 1528.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1528.16, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1528.16, "10th_percentile": 1528.16, "90th_percentile": 1528.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 9551.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $9,551.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 9551.0, "10th_percentile": 9551.0, "90th_percentile": 9551.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $9,551.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 4326.6, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4326.6, "10th_percentile": 4326.6, "90th_percentile": 4326.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 4775.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 4775.5, "10th_percentile": 4775.5, "90th_percentile": 4775.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 5730.6, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 5730.6, "10th_percentile": 5730.6, "90th_percentile": 5730.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 6134.61, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 6134.61, "10th_percentile": 6134.61, "90th_percentile": 6134.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 7163.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 7163.25, "10th_percentile": 7163.25, "90th_percentile": 7163.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 3237.79, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 3237.79, "10th_percentile": 3237.79, "90th_percentile": 3237.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 6685.7, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 6685.7, "10th_percentile": 6685.7, "90th_percentile": 6685.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 7163.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 7163.25, "10th_percentile": 7163.25, "90th_percentile": 7163.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 7640.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 7640.8, "10th_percentile": 7640.8, "90th_percentile": 7640.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 9551.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 9551.0, "10th_percentile": 9551.0, "90th_percentile": 9551.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 1786.04, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1786.04, "10th_percentile": 1786.04, "90th_percentile": 1786.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 2827.1, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2827.1, "10th_percentile": 2827.1, "90th_percentile": 2827.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 7640.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7640.8, "10th_percentile": 7640.8, "90th_percentile": 7640.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 2053.47, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 2053.47, "10th_percentile": 2053.47, "90th_percentile": 2053.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 4775.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4775.5, "10th_percentile": 4775.5, "90th_percentile": 4775.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 8118.35, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 8118.35, "10th_percentile": 8118.35, "90th_percentile": 8118.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1833.79, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1833.79, "10th_percentile": 1833.79, "90th_percentile": 1833.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1833.79, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1833.79, "10th_percentile": 1833.79, "90th_percentile": 1833.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 5424.97, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5424.97, "10th_percentile": 5424.97, "90th_percentile": 5424.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 5424.97, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5424.97, "10th_percentile": 5424.97, "90th_percentile": 5424.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 3737.31, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3737.31, "10th_percentile": 3737.31, "90th_percentile": 3737.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 3737.31, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3737.31, "10th_percentile": 3737.31, "90th_percentile": 3737.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 9551.0, "10th_percentile": 9551.0, "90th_percentile": 9551.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9551.0, "10th_percentile": 9551.0, "90th_percentile": 9551.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9551.0, "10th_percentile": 9551.0, "90th_percentile": 9551.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9551.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9551.0, "10th_percentile": 9551.0, "90th_percentile": 9551.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9551.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9551.0, "10th_percentile": 9551.0, "90th_percentile": 9551.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9551.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9551.0, "10th_percentile": 9551.0, "90th_percentile": 9551.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9551.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9551.0, "10th_percentile": 9551.0, "90th_percentile": 9551.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9551.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9551.0, "10th_percentile": 9551.0, "90th_percentile": 9551.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9551.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9551.0, "10th_percentile": 9551.0, "90th_percentile": 9551.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9551.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9551.0, "10th_percentile": 9551.0, "90th_percentile": 9551.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9551.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9551.0, "10th_percentile": 9551.0, "90th_percentile": 9551.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BODY PROX STD OFFST 65MM", "code_information": [ { "code": "SUP-338642", "type": "CDM" }, { "code": "C1776", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 1065.83, "maximum": 6661.46, "setting": "outpatient", "gross_charge": 6661.46, "discounted_cash": 4663.02, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 3404.01, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2248.51, "10th_percentile": 2248.51, "90th_percentile": 2248.51, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1065.83, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1065.83, "10th_percentile": 1065.83, "90th_percentile": 1065.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 1065.83, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1065.83, "10th_percentile": 1065.83, "90th_percentile": 1065.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1065.83, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1065.83, "10th_percentile": 1065.83, "90th_percentile": 1065.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 6661.46, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,661.46 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 6661.46, "10th_percentile": 6661.46, "90th_percentile": 6661.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,661.46 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 3017.64, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3017.64, "10th_percentile": 3017.64, "90th_percentile": 3017.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 3330.73, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 3330.73, "10th_percentile": 3330.73, "90th_percentile": 3330.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 3996.88, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 3996.88, "10th_percentile": 3996.88, "90th_percentile": 3996.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 4278.66, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 4278.66, "10th_percentile": 4278.66, "90th_percentile": 4278.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 4996.1, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 4996.1, "10th_percentile": 4996.1, "90th_percentile": 4996.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 4663.02, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 4663.02, "10th_percentile": 4663.02, "90th_percentile": 4663.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 4996.1, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 4996.1, "10th_percentile": 4996.1, "90th_percentile": 4996.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 5329.17, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 5329.17, "10th_percentile": 5329.17, "90th_percentile": 5329.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 6661.46, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 6661.46, "10th_percentile": 6661.46, "90th_percentile": 6661.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 1245.69, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1245.69, "10th_percentile": 1245.69, "90th_percentile": 1245.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 1971.79, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1971.79, "10th_percentile": 1971.79, "90th_percentile": 1971.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 5329.17, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5329.17, "10th_percentile": 5329.17, "90th_percentile": 5329.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 3330.73, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3330.73, "10th_percentile": 3330.73, "90th_percentile": 3330.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 5662.24, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 5662.24, "10th_percentile": 5662.24, "90th_percentile": 5662.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1279.0, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1279.0, "10th_percentile": 1279.0, "90th_percentile": 1279.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1279.0, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1279.0, "10th_percentile": 1279.0, "90th_percentile": 1279.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 3783.71, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3783.71, "10th_percentile": 3783.71, "90th_percentile": 3783.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2606.63, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2606.63, "10th_percentile": 2606.63, "90th_percentile": 2606.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2606.63, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2606.63, "10th_percentile": 2606.63, "90th_percentile": 2606.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 6661.46, "10th_percentile": 6661.46, "90th_percentile": 6661.46, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6661.46, "10th_percentile": 6661.46, "90th_percentile": 6661.46, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6661.46, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6661.46, "10th_percentile": 6661.46, "90th_percentile": 6661.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6661.46, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6661.46, "10th_percentile": 6661.46, "90th_percentile": 6661.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6661.46, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6661.46, "10th_percentile": 6661.46, "90th_percentile": 6661.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6661.46, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6661.46, "10th_percentile": 6661.46, "90th_percentile": 6661.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6661.46, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6661.46, "10th_percentile": 6661.46, "90th_percentile": 6661.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6661.46, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6661.46, "10th_percentile": 6661.46, "90th_percentile": 6661.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6661.46, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6661.46, "10th_percentile": 6661.46, "90th_percentile": 6661.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 3783.71, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3783.71, "10th_percentile": 3783.71, "90th_percentile": 3783.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 2258.23, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 2258.23, "10th_percentile": 2258.23, "90th_percentile": 2258.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 1432.21, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 1432.21, "10th_percentile": 1432.21, "90th_percentile": 1432.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6661.46, "10th_percentile": 6661.46, "90th_percentile": 6661.46, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6661.46, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6661.46, "10th_percentile": 6661.46, "90th_percentile": 6661.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BOLT EXT FIX SLOTTED WIRE MR COND MAXFRAME", "code_information": [ { "code": "SUP-420748", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 12.06, "maximum": 86.22, "setting": "outpatient", "gross_charge": 86.22, "discounted_cash": 60.35, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 33.74, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33.74, "10th_percentile": 33.74, "90th_percentile": 33.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 14.6, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.6, "10th_percentile": 14.6, "90th_percentile": 14.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 12.3, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.3, "10th_percentile": 12.3, "90th_percentile": 12.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 12.06, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.06, "10th_percentile": 12.06, "90th_percentile": 12.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 38.18, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.18, "10th_percentile": 38.18, "90th_percentile": 38.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 86.22, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $86.22 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 86.22, "10th_percentile": 86.22, "90th_percentile": 86.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $86.22 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 29.23, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 29.23, "10th_percentile": 29.23, "90th_percentile": 29.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 18.54, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 18.54, "10th_percentile": 18.54, "90th_percentile": 18.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 64.67, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 64.67, "10th_percentile": 64.67, "90th_percentile": 64.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 33.74, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33.74, "10th_percentile": 33.74, "90th_percentile": 33.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 43.11, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 43.11, "10th_percentile": 43.11, "90th_percentile": 43.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 38.18, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.18, "10th_percentile": 38.18, "90th_percentile": 38.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 68.98, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 68.98, "10th_percentile": 68.98, "90th_percentile": 68.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 16.12, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.12, "10th_percentile": 16.12, "90th_percentile": 16.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 25.52, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.52, "10th_percentile": 25.52, "90th_percentile": 25.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 68.98, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 68.98, "10th_percentile": 68.98, "90th_percentile": 68.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 48.97, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 48.97, "10th_percentile": 48.97, "90th_percentile": 48.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 86.22, "10th_percentile": 86.22, "90th_percentile": 86.22, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 86.22, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 86.22, "10th_percentile": 86.22, "90th_percentile": 86.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 86.22, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 86.22, "10th_percentile": 86.22, "90th_percentile": 86.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 73.29, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 73.29, "10th_percentile": 73.29, "90th_percentile": 73.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 55.38, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 55.38, "10th_percentile": 55.38, "90th_percentile": 55.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 43.11, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 43.11, "10th_percentile": 43.11, "90th_percentile": 43.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 60.35, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 60.35, "10th_percentile": 60.35, "90th_percentile": 60.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 64.67, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 64.67, "10th_percentile": 64.67, "90th_percentile": 64.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 51.73, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 51.73, "10th_percentile": 51.73, "90th_percentile": 51.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 86.22, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 86.22, "10th_percentile": 86.22, "90th_percentile": 86.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 39.06, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.06, "10th_percentile": 39.06, "90th_percentile": 39.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 44.06, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 44.06, "10th_percentile": 44.06, "90th_percentile": 44.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 48.97, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 48.97, "10th_percentile": 48.97, "90th_percentile": 48.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 86.22, "10th_percentile": 86.22, "90th_percentile": 86.22, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 86.22, "10th_percentile": 86.22, "90th_percentile": 86.22, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 86.22, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 86.22, "10th_percentile": 86.22, "90th_percentile": 86.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 86.22, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 86.22, "10th_percentile": 86.22, "90th_percentile": 86.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 86.22, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 86.22, "10th_percentile": 86.22, "90th_percentile": 86.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 86.22, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 86.22, "10th_percentile": 86.22, "90th_percentile": 86.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 86.22, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 86.22, "10th_percentile": 86.22, "90th_percentile": 86.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 86.22, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 86.22, "10th_percentile": 86.22, "90th_percentile": 86.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BONE CHP CANC CRUSH 30ML", "code_information": [ { "code": "SUP-130994", "type": "CDM" }, { "code": "C1889", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 110.68, "maximum": 691.77, "setting": "outpatient", "gross_charge": 691.77, "discounted_cash": 484.24, "payers_information": [ { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 691.77, "10th_percentile": 691.77, "90th_percentile": 691.77, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 691.77, "10th_percentile": 691.77, "90th_percentile": 691.77, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 691.77, "10th_percentile": 691.77, "90th_percentile": 691.77, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 204.76, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 101.23, "10th_percentile": 101.23, "90th_percentile": 101.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 691.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $691.77 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 691.77, "10th_percentile": 691.77, "90th_percentile": 691.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $691.77 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 518.83, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 518.83, "10th_percentile": 518.83, "90th_percentile": 518.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 553.42, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 553.42, "10th_percentile": 553.42, "90th_percentile": 553.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 234.51, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 234.51, "10th_percentile": 234.51, "90th_percentile": 234.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 148.73, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 148.73, "10th_percentile": 148.73, "90th_percentile": 148.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 129.36, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 129.36, "10th_percentile": 129.36, "90th_percentile": 129.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 553.42, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 553.42, "10th_percentile": 553.42, "90th_percentile": 553.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 313.37, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 313.37, "10th_percentile": 313.37, "90th_percentile": 313.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 444.32, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 444.32, "10th_percentile": 444.32, "90th_percentile": 444.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 691.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 691.77, "10th_percentile": 691.77, "90th_percentile": 691.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 588.0, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 588.0, "10th_percentile": 588.0, "90th_percentile": 588.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 345.89, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 345.89, "10th_percentile": 345.89, "90th_percentile": 345.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 353.49, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 353.49, "10th_percentile": 353.49, "90th_percentile": 353.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 415.06, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 415.06, "10th_percentile": 415.06, "90th_percentile": 415.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 484.24, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 484.24, "10th_percentile": 484.24, "90th_percentile": 484.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 518.83, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 518.83, "10th_percentile": 518.83, "90th_percentile": 518.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 345.89, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 345.89, "10th_percentile": 345.89, "90th_percentile": 345.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 392.93, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 392.93, "10th_percentile": 392.93, "90th_percentile": 392.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 392.93, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 392.93, "10th_percentile": 392.93, "90th_percentile": 392.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 132.82, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 132.82, "10th_percentile": 132.82, "90th_percentile": 132.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 132.82, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 132.82, "10th_percentile": 132.82, "90th_percentile": 132.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 270.69, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 270.69, "10th_percentile": 270.69, "90th_percentile": 270.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 270.69, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 270.69, "10th_percentile": 270.69, "90th_percentile": 270.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 110.68, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 110.68, "10th_percentile": 110.68, "90th_percentile": 110.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 110.68, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 110.68, "10th_percentile": 110.68, "90th_percentile": 110.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 110.68, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 110.68, "10th_percentile": 110.68, "90th_percentile": 110.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 691.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 691.77, "10th_percentile": 691.77, "90th_percentile": 691.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 691.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 691.77, "10th_percentile": 691.77, "90th_percentile": 691.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 691.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 691.77, "10th_percentile": 691.77, "90th_percentile": 691.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 691.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 691.77, "10th_percentile": 691.77, "90th_percentile": 691.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 691.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 691.77, "10th_percentile": 691.77, "90th_percentile": 691.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 691.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 691.77, "10th_percentile": 691.77, "90th_percentile": 691.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 691.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 691.77, "10th_percentile": 691.77, "90th_percentile": 691.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 691.77, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 691.77, "10th_percentile": 691.77, "90th_percentile": 691.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BREAST LUXE HSC GL IMPLNT SMTH RND LW 500CC", "code_information": [ { "code": "SUP-381654", "type": "CDM" }, { "code": "C1789", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 245.96, "maximum": 1537.26, "setting": "outpatient", "gross_charge": 1537.26, "discounted_cash": 1076.08, "payers_information": [ { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 785.54, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 785.54, "10th_percentile": 785.54, "90th_percentile": 785.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 696.38, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 696.38, "10th_percentile": 696.38, "90th_percentile": 696.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 987.38, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 987.38, "10th_percentile": 987.38, "90th_percentile": 987.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1076.08, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1076.08, "10th_percentile": 1076.08, "90th_percentile": 1076.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 922.36, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 922.36, "10th_percentile": 922.36, "90th_percentile": 922.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 287.47, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 287.47, "10th_percentile": 287.47, "90th_percentile": 287.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1306.67, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1306.67, "10th_percentile": 1306.67, "90th_percentile": 1306.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 521.13, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 521.13, "10th_percentile": 521.13, "90th_percentile": 521.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 455.03, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 455.03, "10th_percentile": 455.03, "90th_percentile": 455.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 330.51, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 330.51, "10th_percentile": 330.51, "90th_percentile": 330.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 768.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 768.63, "10th_percentile": 768.63, "90th_percentile": 768.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 768.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 768.63, "10th_percentile": 768.63, "90th_percentile": 768.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 295.15, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 295.15, "10th_percentile": 295.15, "90th_percentile": 295.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 295.15, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 295.15, "10th_percentile": 295.15, "90th_percentile": 295.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 601.53, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 601.53, "10th_percentile": 601.53, "90th_percentile": 601.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 601.53, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 601.53, "10th_percentile": 601.53, "90th_percentile": 601.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 873.16, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 873.16, "10th_percentile": 873.16, "90th_percentile": 873.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 873.16, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 873.16, "10th_percentile": 873.16, "90th_percentile": 873.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1229.81, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1229.81, "10th_percentile": 1229.81, "90th_percentile": 1229.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1229.81, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1229.81, "10th_percentile": 1229.81, "90th_percentile": 1229.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,537.26 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,537.26 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1152.95, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1152.95, "10th_percentile": 1152.95, "90th_percentile": 1152.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1152.95, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1152.95, "10th_percentile": 1152.95, "90th_percentile": 1152.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 245.96, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 245.96, "10th_percentile": 245.96, "90th_percentile": 245.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 245.96, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 245.96, "10th_percentile": 245.96, "90th_percentile": 245.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 245.96, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 245.96, "10th_percentile": 245.96, "90th_percentile": 245.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BRIMONIDINE 0.2 % OPHT DROP", "drug_information": { "unit": 5.0, "type": "ML" }, "code_information": [ { "code": "RX-17881", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "24208-0411-05", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.9, "maximum": 20.75, "setting": "outpatient", "gross_charge": 20.75, "discounted_cash": 14.52, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 20.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 20.75, "10th_percentile": 20.75, "90th_percentile": 20.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 20.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 20.75, "10th_percentile": 20.75, "90th_percentile": 20.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 20.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 20.75, "10th_percentile": 20.75, "90th_percentile": 20.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 20.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 20.75, "10th_percentile": 20.75, "90th_percentile": 20.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 20.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 20.75, "10th_percentile": 20.75, "90th_percentile": 20.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 20.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 20.75, "10th_percentile": 20.75, "90th_percentile": 20.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 20.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 20.75, "10th_percentile": 20.75, "90th_percentile": 20.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 20.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 20.75, "10th_percentile": 20.75, "90th_percentile": 20.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 9.19, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.19, "10th_percentile": 9.19, "90th_percentile": 9.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 9.19, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.19, "10th_percentile": 9.19, "90th_percentile": 9.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 11.79, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.79, "10th_percentile": 11.79, "90th_percentile": 11.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 7.03, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 7.03, "10th_percentile": 7.03, "90th_percentile": 7.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 4.46, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 4.46, "10th_percentile": 4.46, "90th_percentile": 4.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 8.12, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.12, "10th_percentile": 8.12, "90th_percentile": 8.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 16.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 16.6, "10th_percentile": 16.6, "90th_percentile": 16.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 3.51, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.51, "10th_percentile": 3.51, "90th_percentile": 3.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 2.9, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.9, "10th_percentile": 2.9, "90th_percentile": 2.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2.96, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.96, "10th_percentile": 2.96, "90th_percentile": 2.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 8.12, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.12, "10th_percentile": 8.12, "90th_percentile": 8.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 20.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $20.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 20.75, "10th_percentile": 20.75, "90th_percentile": 20.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $20.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 10.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.38, "10th_percentile": 10.38, "90th_percentile": 10.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 3.88, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.88, "10th_percentile": 3.88, "90th_percentile": 3.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 16.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.6, "10th_percentile": 16.6, "90th_percentile": 16.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 6.14, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.14, "10th_percentile": 6.14, "90th_percentile": 6.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 15.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 15.56, "10th_percentile": 15.56, "90th_percentile": 15.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 11.79, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.79, "10th_percentile": 11.79, "90th_percentile": 11.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 15.56, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 15.56, "10th_percentile": 15.56, "90th_percentile": 15.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 17.64, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 17.64, "10th_percentile": 17.64, "90th_percentile": 17.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 10.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 10.38, "10th_percentile": 10.38, "90th_percentile": 10.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 12.45, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 12.45, "10th_percentile": 12.45, "90th_percentile": 12.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 14.53, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 14.53, "10th_percentile": 14.53, "90th_percentile": 14.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 13.33, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 13.33, "10th_percentile": 13.33, "90th_percentile": 13.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 10.6, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.6, "10th_percentile": 10.6, "90th_percentile": 10.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 9.4, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.4, "10th_percentile": 9.4, "90th_percentile": 9.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 20.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 20.75, "10th_percentile": 20.75, "90th_percentile": 20.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 20.75, "10th_percentile": 20.75, "90th_percentile": 20.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 20.75, "10th_percentile": 20.75, "90th_percentile": 20.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 20.75, "10th_percentile": 20.75, "90th_percentile": 20.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "BROMOCRIPTINE 2.5 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-9297", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "70954-0978-10", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.01, "maximum": 7.25, "setting": "outpatient", "gross_charge": 7.25, "discounted_cash": 5.07, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 1.56, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 1.56, "10th_percentile": 1.56, "90th_percentile": 1.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 2.46, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 2.46, "10th_percentile": 2.46, "90th_percentile": 2.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 1.36, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.36, "10th_percentile": 1.36, "90th_percentile": 1.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 3.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.63, "10th_percentile": 3.63, "90th_percentile": 3.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 3.21, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.21, "10th_percentile": 3.21, "90th_percentile": 3.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 5.44, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 5.44, "10th_percentile": 5.44, "90th_percentile": 5.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 4.66, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 4.66, "10th_percentile": 4.66, "90th_percentile": 4.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 5.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.8, "10th_percentile": 5.8, "90th_percentile": 5.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 3.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 3.63, "10th_percentile": 3.63, "90th_percentile": 3.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 6.16, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 6.16, "10th_percentile": 6.16, "90th_percentile": 6.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 5.44, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 5.44, "10th_percentile": 5.44, "90th_percentile": 5.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 4.35, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 4.35, "10th_percentile": 4.35, "90th_percentile": 4.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 5.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 5.8, "10th_percentile": 5.8, "90th_percentile": 5.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2.84, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.84, "10th_percentile": 2.84, "90th_percentile": 2.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 3.7, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.7, "10th_percentile": 3.7, "90th_percentile": 3.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 3.28, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.28, "10th_percentile": 3.28, "90th_percentile": 3.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 7.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 7.25, "10th_percentile": 7.25, "90th_percentile": 7.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 5.08, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 5.08, "10th_percentile": 5.08, "90th_percentile": 5.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 2.15, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.15, "10th_percentile": 2.15, "90th_percentile": 2.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 7.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $7.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 7.25, "10th_percentile": 7.25, "90th_percentile": 7.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $7.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 3.21, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.21, "10th_percentile": 3.21, "90th_percentile": 3.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.23, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.23, "10th_percentile": 1.23, "90th_percentile": 1.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2.84, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.84, "10th_percentile": 2.84, "90th_percentile": 2.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.03, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.03, "10th_percentile": 1.03, "90th_percentile": 1.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 1.01, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.01, "10th_percentile": 1.01, "90th_percentile": 1.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 4.12, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.12, "10th_percentile": 4.12, "90th_percentile": 4.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 4.12, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.12, "10th_percentile": 4.12, "90th_percentile": 4.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7.25, "10th_percentile": 7.25, "90th_percentile": 7.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7.25, "10th_percentile": 7.25, "90th_percentile": 7.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 7.25, "10th_percentile": 7.25, "90th_percentile": 7.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7.25, "10th_percentile": 7.25, "90th_percentile": 7.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7.25, "10th_percentile": 7.25, "90th_percentile": 7.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7.25, "10th_percentile": 7.25, "90th_percentile": 7.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7.25, "10th_percentile": 7.25, "90th_percentile": 7.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7.25, "10th_percentile": 7.25, "90th_percentile": 7.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7.25, "10th_percentile": 7.25, "90th_percentile": 7.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7.25, "10th_percentile": 7.25, "90th_percentile": 7.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7.25, "10th_percentile": 7.25, "90th_percentile": 7.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BRUSH CYTOLOGY GI LAB BILIARY FUSION 1.5CM FILF G31525", "code_information": [ { "code": "SUP-302581", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 29.89, "maximum": 213.63, "setting": "outpatient", "gross_charge": 213.63, "discounted_cash": 149.54, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 36.17, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 36.17, "10th_percentile": 36.17, "90th_percentile": 36.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 94.6, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 94.6, "10th_percentile": 94.6, "90th_percentile": 94.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 83.59, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 83.59, "10th_percentile": 83.59, "90th_percentile": 83.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 30.49, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 30.49, "10th_percentile": 30.49, "90th_percentile": 30.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 29.89, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 29.89, "10th_percentile": 29.89, "90th_percentile": 29.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 213.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $213.63 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 213.63, "10th_percentile": 213.63, "90th_percentile": 213.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $213.63 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 181.59, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 181.59, "10th_percentile": 181.59, "90th_percentile": 181.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 137.21, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 137.21, "10th_percentile": 137.21, "90th_percentile": 137.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 106.82, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 106.82, "10th_percentile": 106.82, "90th_percentile": 106.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 72.42, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 72.42, "10th_percentile": 72.42, "90th_percentile": 72.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 149.54, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 149.54, "10th_percentile": 149.54, "90th_percentile": 149.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 160.22, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 160.22, "10th_percentile": 160.22, "90th_percentile": 160.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 94.6, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 94.6, "10th_percentile": 94.6, "90th_percentile": 94.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 106.82, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 106.82, "10th_percentile": 106.82, "90th_percentile": 106.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 170.9, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 170.9, "10th_percentile": 170.9, "90th_percentile": 170.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 128.18, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 128.18, "10th_percentile": 128.18, "90th_percentile": 128.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 45.93, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 45.93, "10th_percentile": 45.93, "90th_percentile": 45.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 83.59, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 83.59, "10th_percentile": 83.59, "90th_percentile": 83.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 160.22, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 160.22, "10th_percentile": 160.22, "90th_percentile": 160.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 63.23, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 63.23, "10th_percentile": 63.23, "90th_percentile": 63.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 39.95, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.95, "10th_percentile": 39.95, "90th_percentile": 39.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 170.9, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 170.9, "10th_percentile": 170.9, "90th_percentile": 170.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 213.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 213.63, "10th_percentile": 213.63, "90th_percentile": 213.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 96.77, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 96.77, "10th_percentile": 96.77, "90th_percentile": 96.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 109.16, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 109.16, "10th_percentile": 109.16, "90th_percentile": 109.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 121.34, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 121.34, "10th_percentile": 121.34, "90th_percentile": 121.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 121.34, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 121.34, "10th_percentile": 121.34, "90th_percentile": 121.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 213.63, "10th_percentile": 213.63, "90th_percentile": 213.63, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 213.63, "10th_percentile": 213.63, "90th_percentile": 213.63, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 213.63, "10th_percentile": 213.63, "90th_percentile": 213.63, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 213.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 213.63, "10th_percentile": 213.63, "90th_percentile": 213.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 213.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 213.63, "10th_percentile": 213.63, "90th_percentile": 213.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 213.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 213.63, "10th_percentile": 213.63, "90th_percentile": 213.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 213.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 213.63, "10th_percentile": 213.63, "90th_percentile": 213.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 213.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 213.63, "10th_percentile": 213.63, "90th_percentile": 213.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 213.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 213.63, "10th_percentile": 213.63, "90th_percentile": 213.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 213.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 213.63, "10th_percentile": 213.63, "90th_percentile": 213.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 213.63, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 213.63, "10th_percentile": 213.63, "90th_percentile": 213.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BUDESONIDE 3 MG ORAL CECX", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-31576", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "65162-0778-10", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.68, "maximum": 12.0, "setting": "outpatient", "gross_charge": 12.0, "discounted_cash": 8.4, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 4.07, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 4.07, "10th_percentile": 4.07, "90th_percentile": 4.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 2.24, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.24, "10th_percentile": 2.24, "90th_percentile": 2.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 6.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.0, "10th_percentile": 6.0, "90th_percentile": 6.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 5.31, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.31, "10th_percentile": 5.31, "90th_percentile": 5.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 9.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 7.71, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 7.71, "10th_percentile": 7.71, "90th_percentile": 7.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 9.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.6, "10th_percentile": 9.6, "90th_percentile": 9.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 6.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 6.0, "10th_percentile": 6.0, "90th_percentile": 6.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 10.2, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 10.2, "10th_percentile": 10.2, "90th_percentile": 10.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 9.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 9.0, "10th_percentile": 9.0, "90th_percentile": 9.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 7.2, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 7.2, "10th_percentile": 7.2, "90th_percentile": 7.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 9.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 9.6, "10th_percentile": 9.6, "90th_percentile": 9.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 4.7, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.7, "10th_percentile": 4.7, "90th_percentile": 4.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 6.13, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.13, "10th_percentile": 6.13, "90th_percentile": 6.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 5.44, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.44, "10th_percentile": 5.44, "90th_percentile": 5.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 12.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 8.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 8.4, "10th_percentile": 8.4, "90th_percentile": 8.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 3.55, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.55, "10th_percentile": 3.55, "90th_percentile": 3.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 12.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $12.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $12.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 5.31, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.31, "10th_percentile": 5.31, "90th_percentile": 5.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2.03, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.03, "10th_percentile": 2.03, "90th_percentile": 2.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 4.7, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.7, "10th_percentile": 4.7, "90th_percentile": 4.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.71, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.71, "10th_percentile": 1.71, "90th_percentile": 1.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 1.68, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.68, "10th_percentile": 1.68, "90th_percentile": 1.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 6.82, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.82, "10th_percentile": 6.82, "90th_percentile": 6.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 6.82, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.82, "10th_percentile": 6.82, "90th_percentile": 6.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12.0, "10th_percentile": 12.0, "90th_percentile": 12.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 2.58, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 2.58, "10th_percentile": 2.58, "90th_percentile": 2.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" } ] } ] }, { "description": "BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN", "drug_information": { "unit": 5.0, "type": "ML" }, "code_information": [ { "code": "RX-92831", "type": "CDM" }, { "code": "J0665", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "00409-1159-18", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.92, "maximum": 5.75, "setting": "outpatient", "gross_charge": 5.75, "discounted_cash": 4.02, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5.75, "10th_percentile": 5.75, "90th_percentile": 5.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5.75, "10th_percentile": 5.75, "90th_percentile": 5.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 5.75, "10th_percentile": 5.75, "90th_percentile": 5.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 5.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $5.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 5.75, "10th_percentile": 5.75, "90th_percentile": 5.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $5.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 4.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.6, "10th_percentile": 4.6, "90th_percentile": 4.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 4.31, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 4.31, "10th_percentile": 4.31, "90th_percentile": 4.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 4.89, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 4.89, "10th_percentile": 4.89, "90th_percentile": 4.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 4.31, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 4.31, "10th_percentile": 4.31, "90th_percentile": 4.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 1.24, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 1.24, "10th_percentile": 1.24, "90th_percentile": 1.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 1.95, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 1.95, "10th_percentile": 1.95, "90th_percentile": 1.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 3.45, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 3.45, "10th_percentile": 3.45, "90th_percentile": 3.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 4.03, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 4.03, "10th_percentile": 4.03, "90th_percentile": 4.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 4.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 4.6, "10th_percentile": 4.6, "90th_percentile": 4.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 2.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.88, "10th_percentile": 2.88, "90th_percentile": 2.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 2.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 2.88, "10th_percentile": 2.88, "90th_percentile": 2.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1.1, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.1, "10th_percentile": 1.1, "90th_percentile": 1.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1.1, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.1, "10th_percentile": 1.1, "90th_percentile": 1.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2.25, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2.25, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.92, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.92, "10th_percentile": 0.92, "90th_percentile": 0.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.92, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.92, "10th_percentile": 0.92, "90th_percentile": 0.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.92, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.92, "10th_percentile": 0.92, "90th_percentile": 0.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5.75, "10th_percentile": 5.75, "90th_percentile": 5.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5.75, "10th_percentile": 5.75, "90th_percentile": 5.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5.75, "10th_percentile": 5.75, "90th_percentile": 5.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5.75, "10th_percentile": 5.75, "90th_percentile": 5.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5.75, "10th_percentile": 5.75, "90th_percentile": 5.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5.75, "10th_percentile": 5.75, "90th_percentile": 5.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5.75, "10th_percentile": 5.75, "90th_percentile": 5.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5.75, "10th_percentile": 5.75, "90th_percentile": 5.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 5.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 5.75, "10th_percentile": 5.75, "90th_percentile": 5.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" } ] } ] }, { "description": "BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN", "drug_information": { "unit": 5.0, "type": "ML" }, "code_information": [ { "code": "RX-92832", "type": "CDM" }, { "code": "J0665", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "00143-9331-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.56, "maximum": 3.5, "setting": "outpatient", "gross_charge": 3.5, "discounted_cash": 2.45, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3.5, "10th_percentile": 3.5, "90th_percentile": 3.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 3.5, "10th_percentile": 3.5, "90th_percentile": 3.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 3.5, "10th_percentile": 3.5, "90th_percentile": 3.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 2.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 2.8, "10th_percentile": 2.8, "90th_percentile": 2.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.75, "10th_percentile": 1.75, "90th_percentile": 1.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 2.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.8, "10th_percentile": 2.8, "90th_percentile": 2.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 2.63, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 2.63, "10th_percentile": 2.63, "90th_percentile": 2.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 2.63, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 2.63, "10th_percentile": 2.63, "90th_percentile": 2.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 2.98, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 2.98, "10th_percentile": 2.98, "90th_percentile": 2.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.75, "10th_percentile": 1.75, "90th_percentile": 1.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 2.1, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 2.1, "10th_percentile": 2.1, "90th_percentile": 2.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 2.45, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 2.45, "10th_percentile": 2.45, "90th_percentile": 2.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 3.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 3.5, "10th_percentile": 3.5, "90th_percentile": 3.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 1.19, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 1.19, "10th_percentile": 1.19, "90th_percentile": 1.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.75, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.75, "10th_percentile": 0.75, "90th_percentile": 0.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 3.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 3.5, "10th_percentile": 3.5, "90th_percentile": 3.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $3.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.67, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.67, "10th_percentile": 0.67, "90th_percentile": 0.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.67, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.67, "10th_percentile": 0.67, "90th_percentile": 0.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1.37, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.37, "10th_percentile": 1.37, "90th_percentile": 1.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1.37, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.37, "10th_percentile": 1.37, "90th_percentile": 1.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.56, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.56, "10th_percentile": 0.56, "90th_percentile": 0.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.56, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.56, "10th_percentile": 0.56, "90th_percentile": 0.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.56, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.56, "10th_percentile": 0.56, "90th_percentile": 0.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3.5, "10th_percentile": 3.5, "90th_percentile": 3.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3.5, "10th_percentile": 3.5, "90th_percentile": 3.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3.5, "10th_percentile": 3.5, "90th_percentile": 3.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3.5, "10th_percentile": 3.5, "90th_percentile": 3.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3.5, "10th_percentile": 3.5, "90th_percentile": 3.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3.5, "10th_percentile": 3.5, "90th_percentile": 3.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3.5, "10th_percentile": 3.5, "90th_percentile": 3.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 3.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 3.5, "10th_percentile": 3.5, "90th_percentile": 3.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN", "drug_information": { "unit": 5.0, "type": "ML" }, "code_information": [ { "code": "RX-92832", "type": "CDM" }, { "code": "J0665", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "00409-1162-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.12, "maximum": 7.0, "setting": "outpatient", "gross_charge": 7.0, "discounted_cash": 4.9, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 7.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 7.0, "10th_percentile": 7.0, "90th_percentile": 7.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7.0, "10th_percentile": 7.0, "90th_percentile": 7.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7.0, "10th_percentile": 7.0, "90th_percentile": 7.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7.0, "10th_percentile": 7.0, "90th_percentile": 7.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7.0, "10th_percentile": 7.0, "90th_percentile": 7.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7.0, "10th_percentile": 7.0, "90th_percentile": 7.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7.0, "10th_percentile": 7.0, "90th_percentile": 7.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7.0, "10th_percentile": 7.0, "90th_percentile": 7.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7.0, "10th_percentile": 7.0, "90th_percentile": 7.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7.0, "10th_percentile": 7.0, "90th_percentile": 7.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7.0, "10th_percentile": 7.0, "90th_percentile": 7.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 7.0, "10th_percentile": 7.0, "90th_percentile": 7.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.12, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.12, "10th_percentile": 1.12, "90th_percentile": 1.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.12, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.12, "10th_percentile": 1.12, "90th_percentile": 1.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 1.12, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.12, "10th_percentile": 1.12, "90th_percentile": 1.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2.74, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.74, "10th_percentile": 2.74, "90th_percentile": 2.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2.74, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.74, "10th_percentile": 2.74, "90th_percentile": 2.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1.34, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.34, "10th_percentile": 1.34, "90th_percentile": 1.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1.34, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.34, "10th_percentile": 1.34, "90th_percentile": 1.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 7.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $7.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 7.0, "10th_percentile": 7.0, "90th_percentile": 7.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $7.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 1.51, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 1.51, "10th_percentile": 1.51, "90th_percentile": 1.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 2.37, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 2.37, "10th_percentile": 2.37, "90th_percentile": 2.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 5.95, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 5.95, "10th_percentile": 5.95, "90th_percentile": 5.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 5.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.6, "10th_percentile": 5.6, "90th_percentile": 5.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 5.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 5.6, "10th_percentile": 5.6, "90th_percentile": 5.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 3.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 3.5, "10th_percentile": 3.5, "90th_percentile": 3.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 5.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 5.25, "10th_percentile": 5.25, "90th_percentile": 5.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 5.25, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 5.25, "10th_percentile": 5.25, "90th_percentile": 5.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 4.9, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 4.9, "10th_percentile": 4.9, "90th_percentile": 4.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 3.5, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.5, "10th_percentile": 3.5, "90th_percentile": 3.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 4.2, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 4.2, "10th_percentile": 4.2, "90th_percentile": 4.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" } ] } ] }, { "description": "BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJ SOLN", "drug_information": { "unit": 5.0, "type": "ML" }, "code_information": [ { "code": "RX-1222", "type": "CDM" }, { "code": "J0665", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "00409-1160-18", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.32, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1.7, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1.7, "10th_percentile": 1.7, "90th_percentile": 1.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.43, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.68, "10th_percentile": 0.68, "90th_percentile": 0.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1.2, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1.2, "10th_percentile": 1.2, "90th_percentile": 1.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1.4, "10th_percentile": 1.4, "90th_percentile": 1.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.38, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.38, "10th_percentile": 0.38, "90th_percentile": 0.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.38, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.38, "10th_percentile": 0.38, "90th_percentile": 0.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.32, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.32, "10th_percentile": 0.32, "90th_percentile": 0.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.32, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.32, "10th_percentile": 0.32, "90th_percentile": 0.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.32, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.32, "10th_percentile": 0.32, "90th_percentile": 0.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BUPIVACAINE HCL 0.5 % (5 MG/ML) INJ SOLN", "drug_information": { "unit": 50.0, "type": "ML" }, "code_information": [ { "code": "RX-1223", "type": "CDM" }, { "code": "J0665", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "00409-1163-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 2.16, "maximum": 13.5, "setting": "outpatient", "gross_charge": 13.5, "discounted_cash": 9.45, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 13.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $13.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $13.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 10.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.8, "10th_percentile": 10.8, "90th_percentile": 10.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 10.13, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 10.13, "10th_percentile": 10.13, "90th_percentile": 10.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 11.48, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 11.48, "10th_percentile": 11.48, "90th_percentile": 11.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 10.13, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 10.13, "10th_percentile": 10.13, "90th_percentile": 10.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 2.9, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 2.9, "10th_percentile": 2.9, "90th_percentile": 2.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 4.58, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 4.58, "10th_percentile": 4.58, "90th_percentile": 4.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 13.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 8.1, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 8.1, "10th_percentile": 8.1, "90th_percentile": 8.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 9.45, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 9.45, "10th_percentile": 9.45, "90th_percentile": 9.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 10.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 10.8, "10th_percentile": 10.8, "90th_percentile": 10.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 6.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.75, "10th_percentile": 6.75, "90th_percentile": 6.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 6.75, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 6.75, "10th_percentile": 6.75, "90th_percentile": 6.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 2.59, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.59, "10th_percentile": 2.59, "90th_percentile": 2.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 2.59, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.59, "10th_percentile": 2.59, "90th_percentile": 2.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 5.28, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.28, "10th_percentile": 5.28, "90th_percentile": 5.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 5.28, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.28, "10th_percentile": 5.28, "90th_percentile": 5.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2.16, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.16, "10th_percentile": 2.16, "90th_percentile": 2.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 2.16, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.16, "10th_percentile": 2.16, "90th_percentile": 2.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2.16, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.16, "10th_percentile": 2.16, "90th_percentile": 2.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 13.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 13.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 13.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 13.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 13.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 13.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 13.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 13.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 13.5, "10th_percentile": 13.5, "90th_percentile": 13.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN", "drug_information": { "unit": 5.0, "type": "ML" }, "code_information": [ { "code": "RX-92830", "type": "CDM" }, { "code": "25000000", "type": "LOCAL" }, { "code": "0250", "type": "RC" }, { "code": "63323-0468-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.71, "maximum": 12.25, "setting": "outpatient", "gross_charge": 12.25, "discounted_cash": 8.57, "payers_information": [ { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2.07, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.07, "10th_percentile": 2.07, "90th_percentile": 2.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 1.71, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.71, "10th_percentile": 1.71, "90th_percentile": 1.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.75, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.75, "10th_percentile": 1.75, "90th_percentile": 1.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 4.79, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.79, "10th_percentile": 4.79, "90th_percentile": 4.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 12.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $12.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $12.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 5.42, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.42, "10th_percentile": 5.42, "90th_percentile": 5.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 6.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.13, "10th_percentile": 6.13, "90th_percentile": 6.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 2.29, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.29, "10th_percentile": 2.29, "90th_percentile": 2.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 9.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.8, "10th_percentile": 9.8, "90th_percentile": 9.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 3.63, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.63, "10th_percentile": 3.63, "90th_percentile": 3.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 9.19, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 9.19, "10th_percentile": 9.19, "90th_percentile": 9.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 6.96, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.96, "10th_percentile": 6.96, "90th_percentile": 6.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 9.19, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 9.19, "10th_percentile": 9.19, "90th_percentile": 9.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 10.41, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 10.41, "10th_percentile": 10.41, "90th_percentile": 10.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 6.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 6.13, "10th_percentile": 6.13, "90th_percentile": 6.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 7.35, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 7.35, "10th_percentile": 7.35, "90th_percentile": 7.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 8.58, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 8.58, "10th_percentile": 8.58, "90th_percentile": 8.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 7.87, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 7.87, "10th_percentile": 7.87, "90th_percentile": 7.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 6.26, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.26, "10th_percentile": 6.26, "90th_percentile": 6.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 5.55, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.55, "10th_percentile": 5.55, "90th_percentile": 5.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 12.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 6.96, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.96, "10th_percentile": 6.96, "90th_percentile": 6.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 4.15, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 4.15, "10th_percentile": 4.15, "90th_percentile": 4.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 2.63, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 2.63, "10th_percentile": 2.63, "90th_percentile": 2.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 4.79, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.79, "10th_percentile": 4.79, "90th_percentile": 4.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 5.42, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.42, "10th_percentile": 5.42, "90th_percentile": 5.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 9.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 9.8, "10th_percentile": 9.8, "90th_percentile": 9.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 12.25, "10th_percentile": 12.25, "90th_percentile": 12.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "BUPRENORPHINE HCL 2 MG SL SUBL", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-92462", "type": "CDM" }, { "code": "J0571", "type": "HCPCS" }, { "code": "0637", "type": "RC" }, { "code": "62756-0459-83", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.32, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.68, "10th_percentile": 0.68, "90th_percentile": 0.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.43, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.38, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.38, "10th_percentile": 0.38, "90th_percentile": 0.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.32, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.32, "10th_percentile": 0.32, "90th_percentile": 0.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.32, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.32, "10th_percentile": 0.32, "90th_percentile": 0.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.32, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.32, "10th_percentile": 0.32, "90th_percentile": 0.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.38, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.38, "10th_percentile": 0.38, "90th_percentile": 0.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1.7, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1.7, "10th_percentile": 1.7, "90th_percentile": 1.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1.2, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1.2, "10th_percentile": 1.2, "90th_percentile": 1.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1.4, "10th_percentile": 1.4, "90th_percentile": 1.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1.28, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1.28, "10th_percentile": 1.28, "90th_percentile": 1.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1.02, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.02, "10th_percentile": 1.02, "90th_percentile": 1.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 0.91, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.91, "10th_percentile": 0.91, "90th_percentile": 0.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" } ] } ] }, { "description": "BUPRENORPHINE-NALOXONE 8-2 MG SL FILM", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-184166", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "43598-0582-30", "type": "NDC" } ], "standard_charges": [ { "minimum": 1.36, "maximum": 9.75, "setting": "outpatient", "gross_charge": 9.75, "discounted_cash": 6.82, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 3.31, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 3.31, "10th_percentile": 3.31, "90th_percentile": 3.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 1.82, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.82, "10th_percentile": 1.82, "90th_percentile": 1.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 4.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.88, "10th_percentile": 4.88, "90th_percentile": 4.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 4.32, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.32, "10th_percentile": 4.32, "90th_percentile": 4.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 7.31, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 7.31, "10th_percentile": 7.31, "90th_percentile": 7.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 6.26, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 6.26, "10th_percentile": 6.26, "90th_percentile": 6.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 7.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7.8, "10th_percentile": 7.8, "90th_percentile": 7.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 4.88, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 4.88, "10th_percentile": 4.88, "90th_percentile": 4.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 8.29, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 8.29, "10th_percentile": 8.29, "90th_percentile": 8.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 7.31, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 7.31, "10th_percentile": 7.31, "90th_percentile": 7.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 5.85, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 5.85, "10th_percentile": 5.85, "90th_percentile": 5.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 7.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 7.8, "10th_percentile": 7.8, "90th_percentile": 7.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 3.82, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.82, "10th_percentile": 3.82, "90th_percentile": 3.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 4.98, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.98, "10th_percentile": 4.98, "90th_percentile": 4.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 4.42, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.42, "10th_percentile": 4.42, "90th_percentile": 4.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 9.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 9.75, "10th_percentile": 9.75, "90th_percentile": 9.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 6.83, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 6.83, "10th_percentile": 6.83, "90th_percentile": 6.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 2.89, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.89, "10th_percentile": 2.89, "90th_percentile": 2.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 9.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $9.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 9.75, "10th_percentile": 9.75, "90th_percentile": 9.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $9.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 4.32, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.32, "10th_percentile": 4.32, "90th_percentile": 4.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.65, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.65, "10th_percentile": 1.65, "90th_percentile": 1.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 3.82, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.82, "10th_percentile": 3.82, "90th_percentile": 3.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.39, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.39, "10th_percentile": 1.39, "90th_percentile": 1.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 1.36, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.36, "10th_percentile": 1.36, "90th_percentile": 1.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 5.54, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.54, "10th_percentile": 5.54, "90th_percentile": 5.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 5.54, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.54, "10th_percentile": 5.54, "90th_percentile": 5.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9.75, "10th_percentile": 9.75, "90th_percentile": 9.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 9.75, "10th_percentile": 9.75, "90th_percentile": 9.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 9.75, "10th_percentile": 9.75, "90th_percentile": 9.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9.75, "10th_percentile": 9.75, "90th_percentile": 9.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9.75, "10th_percentile": 9.75, "90th_percentile": 9.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9.75, "10th_percentile": 9.75, "90th_percentile": 9.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9.75, "10th_percentile": 9.75, "90th_percentile": 9.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9.75, "10th_percentile": 9.75, "90th_percentile": 9.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9.75, "10th_percentile": 9.75, "90th_percentile": 9.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9.75, "10th_percentile": 9.75, "90th_percentile": 9.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 9.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 9.75, "10th_percentile": 9.75, "90th_percentile": 9.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 2.1, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 2.1, "10th_percentile": 2.1, "90th_percentile": 2.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" } ] } ] }, { "description": "BUR SURGICAL HEAD 3MM CARBIDE MATCH", "code_information": [ { "code": "SUP-349841", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 76.7, "maximum": 548.26, "setting": "outpatient", "gross_charge": 548.26, "discounted_cash": 383.78, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 92.82, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 92.82, "10th_percentile": 92.82, "90th_percentile": 92.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 242.77, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 242.77, "10th_percentile": 242.77, "90th_percentile": 242.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 214.53, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 214.53, "10th_percentile": 214.53, "90th_percentile": 214.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 78.24, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 78.24, "10th_percentile": 78.24, "90th_percentile": 78.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 76.7, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 76.7, "10th_percentile": 76.7, "90th_percentile": 76.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 548.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $548.26 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 548.26, "10th_percentile": 548.26, "90th_percentile": 548.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $548.26 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 466.02, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 466.02, "10th_percentile": 466.02, "90th_percentile": 466.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 352.15, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 352.15, "10th_percentile": 352.15, "90th_percentile": 352.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 274.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 274.13, "10th_percentile": 274.13, "90th_percentile": 274.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 185.86, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 185.86, "10th_percentile": 185.86, "90th_percentile": 185.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 383.78, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 383.78, "10th_percentile": 383.78, "90th_percentile": 383.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 411.2, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 411.2, "10th_percentile": 411.2, "90th_percentile": 411.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 242.77, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 242.77, "10th_percentile": 242.77, "90th_percentile": 242.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 274.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 274.13, "10th_percentile": 274.13, "90th_percentile": 274.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 438.61, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 438.61, "10th_percentile": 438.61, "90th_percentile": 438.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 328.96, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 328.96, "10th_percentile": 328.96, "90th_percentile": 328.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 117.88, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 117.88, "10th_percentile": 117.88, "90th_percentile": 117.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 214.53, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 214.53, "10th_percentile": 214.53, "90th_percentile": 214.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 411.2, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 411.2, "10th_percentile": 411.2, "90th_percentile": 411.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 162.28, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 162.28, "10th_percentile": 162.28, "90th_percentile": 162.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 102.52, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 102.52, "10th_percentile": 102.52, "90th_percentile": 102.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 438.61, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 438.61, "10th_percentile": 438.61, "90th_percentile": 438.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 548.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 548.26, "10th_percentile": 548.26, "90th_percentile": 548.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 248.36, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 248.36, "10th_percentile": 248.36, "90th_percentile": 248.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 280.16, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 280.16, "10th_percentile": 280.16, "90th_percentile": 280.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 311.41, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 311.41, "10th_percentile": 311.41, "90th_percentile": 311.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 311.41, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 311.41, "10th_percentile": 311.41, "90th_percentile": 311.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 548.26, "10th_percentile": 548.26, "90th_percentile": 548.26, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 548.26, "10th_percentile": 548.26, "90th_percentile": 548.26, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 548.26, "10th_percentile": 548.26, "90th_percentile": 548.26, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 548.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 548.26, "10th_percentile": 548.26, "90th_percentile": 548.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 548.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 548.26, "10th_percentile": 548.26, "90th_percentile": 548.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 548.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 548.26, "10th_percentile": 548.26, "90th_percentile": 548.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 548.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 548.26, "10th_percentile": 548.26, "90th_percentile": 548.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 548.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 548.26, "10th_percentile": 548.26, "90th_percentile": 548.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 548.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 548.26, "10th_percentile": 548.26, "90th_percentile": 548.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 548.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 548.26, "10th_percentile": 548.26, "90th_percentile": 548.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 548.26, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 548.26, "10th_percentile": 548.26, "90th_percentile": 548.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BURR 45MM STRG TPR FLT END", "code_information": [ { "code": "SUP-414203", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 1.17, "maximum": 8.38, "setting": "outpatient", "gross_charge": 8.38, "discounted_cash": 5.87, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 3.28, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.28, "10th_percentile": 3.28, "90th_percentile": 3.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 3.28, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.28, "10th_percentile": 3.28, "90th_percentile": 3.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 3.71, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.71, "10th_percentile": 3.71, "90th_percentile": 3.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 3.71, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.71, "10th_percentile": 3.71, "90th_percentile": 3.71, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 4.76, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.76, "10th_percentile": 4.76, "90th_percentile": 4.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 6.29, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 6.29, "10th_percentile": 6.29, "90th_percentile": 6.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 5.87, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 5.87, "10th_percentile": 5.87, "90th_percentile": 5.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 6.29, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 6.29, "10th_percentile": 6.29, "90th_percentile": 6.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 4.19, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.19, "10th_percentile": 4.19, "90th_percentile": 4.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 4.19, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 4.19, "10th_percentile": 4.19, "90th_percentile": 4.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 6.7, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 6.7, "10th_percentile": 6.7, "90th_percentile": 6.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 5.03, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 5.03, "10th_percentile": 5.03, "90th_percentile": 5.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 5.38, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 5.38, "10th_percentile": 5.38, "90th_percentile": 5.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 7.12, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 7.12, "10th_percentile": 7.12, "90th_percentile": 7.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 3.8, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.8, "10th_percentile": 3.8, "90th_percentile": 3.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 4.28, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.28, "10th_percentile": 4.28, "90th_percentile": 4.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 8.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 8.38, "10th_percentile": 8.38, "90th_percentile": 8.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 1.57, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.57, "10th_percentile": 1.57, "90th_percentile": 1.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 6.7, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6.7, "10th_percentile": 6.7, "90th_percentile": 6.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 2.48, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.48, "10th_percentile": 2.48, "90th_percentile": 2.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 8.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8.38 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 8.38, "10th_percentile": 8.38, "90th_percentile": 8.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8.38 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.42, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.42, "10th_percentile": 1.42, "90th_percentile": 1.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 1.17, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.17, "10th_percentile": 1.17, "90th_percentile": 1.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1.2, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.2, "10th_percentile": 1.2, "90th_percentile": 1.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 8.38, "10th_percentile": 8.38, "90th_percentile": 8.38, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8.38, "10th_percentile": 8.38, "90th_percentile": 8.38, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8.38, "10th_percentile": 8.38, "90th_percentile": 8.38, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 8.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 8.38, "10th_percentile": 8.38, "90th_percentile": 8.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 8.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 8.38, "10th_percentile": 8.38, "90th_percentile": 8.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 8.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 8.38, "10th_percentile": 8.38, "90th_percentile": 8.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 8.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 8.38, "10th_percentile": 8.38, "90th_percentile": 8.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 8.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 8.38, "10th_percentile": 8.38, "90th_percentile": 8.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 8.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 8.38, "10th_percentile": 8.38, "90th_percentile": 8.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 8.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 8.38, "10th_percentile": 8.38, "90th_percentile": 8.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 2.84, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 2.84, "10th_percentile": 2.84, "90th_percentile": 2.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 1.8, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 1.8, "10th_percentile": 1.8, "90th_percentile": 1.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 4.76, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.76, "10th_percentile": 4.76, "90th_percentile": 4.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 8.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 8.38, "10th_percentile": 8.38, "90th_percentile": 8.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "BUSPIRONE 15 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-17464", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "16729-0203-12", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.89, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.89, "10th_percentile": 0.89, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.89, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.89, "10th_percentile": 0.89, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.68, "10th_percentile": 0.68, "90th_percentile": 0.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.28, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.28, "10th_percentile": 0.28, "90th_percentile": 0.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.43, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.34, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.34, "10th_percentile": 0.34, "90th_percentile": 0.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.37, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.37, "10th_percentile": 0.37, "90th_percentile": 0.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.29, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.29, "10th_percentile": 0.29, "90th_percentile": 0.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1.7, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1.7, "10th_percentile": 1.7, "90th_percentile": 1.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1.28, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1.28, "10th_percentile": 1.28, "90th_percentile": 1.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1.02, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.02, "10th_percentile": 1.02, "90th_percentile": 1.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.59, "10th_percentile": 0.59, "90th_percentile": 0.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 0.91, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.91, "10th_percentile": 0.91, "90th_percentile": 0.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1.2, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1.2, "10th_percentile": 1.2, "90th_percentile": 1.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1.4, "10th_percentile": 1.4, "90th_percentile": 1.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" } ] } ] }, { "description": "BUSPIRONE 15 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-17464", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "60687-0823-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.31, "maximum": 2.25, "setting": "outpatient", "gross_charge": 2.25, "discounted_cash": 1.57, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 0.67, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.67, "10th_percentile": 0.67, "90th_percentile": 0.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.42, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.42, "10th_percentile": 0.42, "90th_percentile": 0.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.48, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.48, "10th_percentile": 0.48, "90th_percentile": 0.48, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1.58, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1.58, "10th_percentile": 1.58, "90th_percentile": 1.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1.35, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1.35, "10th_percentile": 1.35, "90th_percentile": 1.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1.0, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.88, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.88, "10th_percentile": 0.88, "90th_percentile": 0.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.76, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.76, "10th_percentile": 0.76, "90th_percentile": 0.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1.91, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1.91, "10th_percentile": 1.91, "90th_percentile": 1.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1.15, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.15, "10th_percentile": 1.15, "90th_percentile": 1.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1.45, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1.45, "10th_percentile": 1.45, "90th_percentile": 1.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 1.02, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.02, "10th_percentile": 1.02, "90th_percentile": 1.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.8, "10th_percentile": 1.8, "90th_percentile": 1.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1.8, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1.8, "10th_percentile": 1.8, "90th_percentile": 1.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.13, "10th_percentile": 1.13, "90th_percentile": 1.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.13, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.13, "10th_percentile": 1.13, "90th_percentile": 1.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1.69, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1.69, "10th_percentile": 1.69, "90th_percentile": 1.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1.69, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1.69, "10th_percentile": 1.69, "90th_percentile": 1.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.88, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.88, "10th_percentile": 0.88, "90th_percentile": 0.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.38, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.38, "10th_percentile": 0.38, "90th_percentile": 0.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.32, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.32, "10th_percentile": 0.32, "90th_percentile": 0.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.31, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.31, "10th_percentile": 0.31, "90th_percentile": 0.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1.0, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.28, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.28, "10th_percentile": 1.28, "90th_percentile": 1.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.28, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.28, "10th_percentile": 1.28, "90th_percentile": 1.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "Biopsy Penis Separate Procedure", "code_information": [ { "code": "CASE-54100", "type": "LOCAL" }, { "code": "54100", "type": "CPT" }, { "code": "0360", "type": "RC" } ], "standard_charges": [ { "minimum": 2137.0, "maximum": 2374.0, "setting": "outpatient", "gross_charge": 19097.03, "discounted_cash": 13367.92, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.727859160; Using new claim; Scope: All Financial Classes; Cases: 1; APCs; 100% Billed, and; Pricing Extension - NM HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR NWR; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $19,097.03 @ 12.5% = $2,387.13 due to $0.00 Claim Price", "median_amount": 2387.13, "10th_percentile": 2387.13, "90th_percentile": 2387.13, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.727859160; Using new claim; Scope: All Financial Classes; Cases: 1; APCs; 100% Billed, and; Pricing Extension - NM HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR NWR; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $19,097.03 @ 12.5% = $2,387.13 due to $0.00 Claim Price" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Re-evaluated: HLB.727859160; Using new claim; Scope: All Financial Classes; Cases: 1; APCs; 100% Billed, and; Pricing Extension - NM HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR NWR; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $19,097.03 @ 12.5% = $2,387.13 due to $0.00 Claim Price", "median_amount": 2387.13, "10th_percentile": 2387.13, "90th_percentile": 2387.13, "count": "1 through 10", "methodology": "other", "additional_payer_notes": "Re-evaluated: HLB.727859160; Using new claim; Scope: All Financial Classes; Cases: 1; APCs; 100% Billed, and; Pricing Extension - NM HB XR MULT PRICE 3M $0 RETURN & HAS APC FOR NWR; Note: Multiple pricing methods applied. Percent of APC: $0.00 @ 100% = $0.00. Percent of Claim Billed: $19,097.03 @ 12.5% = $2,387.13 due to $0.00 Claim Price" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 19097.03, "10th_percentile": 19097.03, "90th_percentile": 19097.03, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 19097.03, "10th_percentile": 19097.03, "90th_percentile": 19097.03, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 19097.03, "10th_percentile": 19097.03, "90th_percentile": 19097.03, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 19097.03, "10th_percentile": 19097.03, "90th_percentile": 19097.03, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 19097.03, "10th_percentile": 19097.03, "90th_percentile": 19097.03, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 19097.03, "10th_percentile": 19097.03, "90th_percentile": 19097.03, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 19097.03, "10th_percentile": 19097.03, "90th_percentile": 19097.03, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 19097.03, "10th_percentile": 19097.03, "90th_percentile": 19097.03, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 19097.03, "10th_percentile": 19097.03, "90th_percentile": 19097.03, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_percentage": 100.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 19097.03, "10th_percentile": 19097.03, "90th_percentile": 19097.03, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_percentage": 42.2, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 8058.95, "10th_percentile": 8058.95, "90th_percentile": 8058.95, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_percentage": 33.9, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 6473.88, "10th_percentile": 6473.88, "90th_percentile": 6473.88, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_percentage": 21.5, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 4105.87, "10th_percentile": 4105.87, "90th_percentile": 4105.87, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_percentage": 32.2, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 6149.26, "10th_percentile": 6149.26, "90th_percentile": 6149.26, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 15277.62, "10th_percentile": 15277.62, "90th_percentile": 15277.62, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_percentage": 17.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 3303.79, "10th_percentile": 3303.79, "90th_percentile": 3303.79, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_percentage": 17.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 3303.79, "10th_percentile": 3303.79, "90th_percentile": 3303.79, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_percentage": 17.3, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 3303.79, "10th_percentile": 3303.79, "90th_percentile": 3303.79, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_percentage": 32.2, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 6149.26, "10th_percentile": 6149.26, "90th_percentile": 6149.26, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 9548.55, "10th_percentile": 9548.55, "90th_percentile": 9548.55, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_percentage": 18.7, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 3574.69, "10th_percentile": 3574.69, "90th_percentile": 3574.69, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 15277.62, "10th_percentile": 15277.62, "90th_percentile": 15277.62, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_percentage": 29.6, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 5634.6, "10th_percentile": 5634.6, "90th_percentile": 5634.6, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 14322.78, "10th_percentile": 14322.78, "90th_percentile": 14322.78, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_percentage": 42.2, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 8058.95, "10th_percentile": 8058.95, "90th_percentile": 8058.95, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 14322.78, "10th_percentile": 14322.78, "90th_percentile": 14322.78, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_percentage": 85.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 16232.5, "10th_percentile": 16232.5, "90th_percentile": 16232.5, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 9548.55, "10th_percentile": 9548.55, "90th_percentile": 9548.55, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_percentage": 60.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 11458.22, "10th_percentile": 11458.22, "90th_percentile": 11458.22, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_percentage": 70.0, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 13367.95, "10th_percentile": 13367.95, "90th_percentile": 13367.95, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_percentage": 64.23, "standard_charge_algorithm": "Additional anesthesia services, drugs, labs, supplies, and other services can be included in reimbursement.", "median_amount": 12165.38, "10th_percentile": 12165.38, "90th_percentile": 12165.38, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_percentage": 39.13, "standard_charge_algorithm": "Additional drugs, labs, and supplies can be included in reimbursement.", "median_amount": 4242.0, "10th_percentile": 4242.0, "90th_percentile": 4242.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_percentage": 39.13, "standard_charge_algorithm": "Additional drugs, labs, and supplies can be included in reimbursement.", "median_amount": 4242.0, "10th_percentile": 4242.0, "90th_percentile": 4242.0, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 2137.0, "standard_charge_algorithm": "Re-evaluated: HLB.727859160; Using new claim; Scope: All Financial Classes; Cases: 1; OP Surgery Group 2; Case Rate @ $2,137.00, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2185.69, "10th_percentile": 2185.69, "90th_percentile": 2185.69, "count": "1 through 10", "methodology": "case rate" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 2374.0, "standard_charge_algorithm": "Re-evaluated: HLB.727859160; Using new claim; Scope: All Financial Classes; Cases: 1; OP Surgery Group 2; Case Rate @ $2,374.00, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2422.69, "10th_percentile": 2422.69, "90th_percentile": 2422.69, "count": "1 through 10", "methodology": "case rate" } ] } ] }, { "description": "CAGE ORIO-C PEEK CRVCL ANATOM W/ ANCHR LRG 14X17X4M", "code_information": [ { "code": "SUP-392831", "type": "CDM" }, { "code": "C1889", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 327.95, "maximum": 2049.68, "setting": "outpatient", "gross_charge": 2049.68, "discounted_cash": 1434.78, "payers_information": [ { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2049.68, "10th_percentile": 2049.68, "90th_percentile": 2049.68, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2049.68, "10th_percentile": 2049.68, "90th_percentile": 2049.68, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2049.68, "10th_percentile": 2049.68, "90th_percentile": 2049.68, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 606.71, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 101.23, "10th_percentile": 101.23, "90th_percentile": 101.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2049.68, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,049.68 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2049.68, "10th_percentile": 2049.68, "90th_percentile": 2049.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,049.68 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2049.68, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2049.68, "10th_percentile": 2049.68, "90th_percentile": 2049.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 928.51, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 928.51, "10th_percentile": 928.51, "90th_percentile": 928.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 694.84, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 694.84, "10th_percentile": 694.84, "90th_percentile": 694.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1316.51, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1316.51, "10th_percentile": 1316.51, "90th_percentile": 1316.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1434.78, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1434.78, "10th_percentile": 1434.78, "90th_percentile": 1434.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1742.23, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1742.23, "10th_percentile": 1742.23, "90th_percentile": 1742.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1024.84, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1024.84, "10th_percentile": 1024.84, "90th_percentile": 1024.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1047.39, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1047.39, "10th_percentile": 1047.39, "90th_percentile": 1047.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1639.74, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1639.74, "10th_percentile": 1639.74, "90th_percentile": 1639.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 383.29, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 383.29, "10th_percentile": 383.29, "90th_percentile": 383.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1537.26, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1537.26, "10th_percentile": 1537.26, "90th_percentile": 1537.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1229.81, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1229.81, "10th_percentile": 1229.81, "90th_percentile": 1229.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1024.84, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1024.84, "10th_percentile": 1024.84, "90th_percentile": 1024.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1639.74, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1639.74, "10th_percentile": 1639.74, "90th_percentile": 1639.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 440.68, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 440.68, "10th_percentile": 440.68, "90th_percentile": 440.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 393.54, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 393.54, "10th_percentile": 393.54, "90th_percentile": 393.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 393.54, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 393.54, "10th_percentile": 393.54, "90th_percentile": 393.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 802.04, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 802.04, "10th_percentile": 802.04, "90th_percentile": 802.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 802.04, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 802.04, "10th_percentile": 802.04, "90th_percentile": 802.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1164.22, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1164.22, "10th_percentile": 1164.22, "90th_percentile": 1164.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1164.22, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1164.22, "10th_percentile": 1164.22, "90th_percentile": 1164.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 327.95, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 327.95, "10th_percentile": 327.95, "90th_percentile": 327.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 327.95, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 327.95, "10th_percentile": 327.95, "90th_percentile": 327.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 327.95, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 327.95, "10th_percentile": 327.95, "90th_percentile": 327.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2049.68, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2049.68, "10th_percentile": 2049.68, "90th_percentile": 2049.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2049.68, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2049.68, "10th_percentile": 2049.68, "90th_percentile": 2049.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2049.68, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2049.68, "10th_percentile": 2049.68, "90th_percentile": 2049.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2049.68, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2049.68, "10th_percentile": 2049.68, "90th_percentile": 2049.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2049.68, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2049.68, "10th_percentile": 2049.68, "90th_percentile": 2049.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2049.68, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2049.68, "10th_percentile": 2049.68, "90th_percentile": 2049.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2049.68, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2049.68, "10th_percentile": 2049.68, "90th_percentile": 2049.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2049.68, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2049.68, "10th_percentile": 2049.68, "90th_percentile": 2049.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "CAGE ORIO-TL STR TLIF GEN II 10M W 10 X10 X26M", "code_information": [ { "code": "SUP-392880", "type": "CDM" }, { "code": "C1889", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 1180.62, "maximum": 7378.85, "setting": "outpatient", "gross_charge": 7378.85, "discounted_cash": 5165.19, "payers_information": [ { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 7378.85, "10th_percentile": 7378.85, "90th_percentile": 7378.85, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7378.85, "10th_percentile": 7378.85, "90th_percentile": 7378.85, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7378.85, "10th_percentile": 7378.85, "90th_percentile": 7378.85, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 2184.14, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 101.23, "10th_percentile": 101.23, "90th_percentile": 101.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 7378.85, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $7,378.85 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 7378.85, "10th_percentile": 7378.85, "90th_percentile": 7378.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $7,378.85 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 5534.14, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 5534.14, "10th_percentile": 5534.14, "90th_percentile": 5534.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 5903.08, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 5903.08, "10th_percentile": 5903.08, "90th_percentile": 5903.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 2501.43, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 2501.43, "10th_percentile": 2501.43, "90th_percentile": 2501.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 1586.45, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 1586.45, "10th_percentile": 1586.45, "90th_percentile": 1586.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 1379.84, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1379.84, "10th_percentile": 1379.84, "90th_percentile": 1379.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 5903.08, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5903.08, "10th_percentile": 5903.08, "90th_percentile": 5903.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 3342.62, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3342.62, "10th_percentile": 3342.62, "90th_percentile": 3342.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 4739.44, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 4739.44, "10th_percentile": 4739.44, "90th_percentile": 4739.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 7378.85, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 7378.85, "10th_percentile": 7378.85, "90th_percentile": 7378.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 6272.02, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 6272.02, "10th_percentile": 6272.02, "90th_percentile": 6272.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 3689.43, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3689.43, "10th_percentile": 3689.43, "90th_percentile": 3689.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 3770.59, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3770.59, "10th_percentile": 3770.59, "90th_percentile": 3770.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 4427.31, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 4427.31, "10th_percentile": 4427.31, "90th_percentile": 4427.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 5165.2, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 5165.2, "10th_percentile": 5165.2, "90th_percentile": 5165.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 5534.14, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 5534.14, "10th_percentile": 5534.14, "90th_percentile": 5534.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 3689.43, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 3689.43, "10th_percentile": 3689.43, "90th_percentile": 3689.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 4191.19, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4191.19, "10th_percentile": 4191.19, "90th_percentile": 4191.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 4191.19, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4191.19, "10th_percentile": 4191.19, "90th_percentile": 4191.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1416.74, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1416.74, "10th_percentile": 1416.74, "90th_percentile": 1416.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1416.74, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1416.74, "10th_percentile": 1416.74, "90th_percentile": 1416.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2887.34, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2887.34, "10th_percentile": 2887.34, "90th_percentile": 2887.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2887.34, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2887.34, "10th_percentile": 2887.34, "90th_percentile": 2887.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 1180.62, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1180.62, "10th_percentile": 1180.62, "90th_percentile": 1180.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1180.62, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1180.62, "10th_percentile": 1180.62, "90th_percentile": 1180.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1180.62, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1180.62, "10th_percentile": 1180.62, "90th_percentile": 1180.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7378.85, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7378.85, "10th_percentile": 7378.85, "90th_percentile": 7378.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7378.85, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7378.85, "10th_percentile": 7378.85, "90th_percentile": 7378.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7378.85, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7378.85, "10th_percentile": 7378.85, "90th_percentile": 7378.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7378.85, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7378.85, "10th_percentile": 7378.85, "90th_percentile": 7378.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7378.85, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7378.85, "10th_percentile": 7378.85, "90th_percentile": 7378.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7378.85, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7378.85, "10th_percentile": 7378.85, "90th_percentile": 7378.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7378.85, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7378.85, "10th_percentile": 7378.85, "90th_percentile": 7378.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7378.85, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7378.85, "10th_percentile": 7378.85, "90th_percentile": 7378.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "CAGE SP 10X28X8-13 7DEG LRD INTRBDY SLF EXP PROLIFT PL", "code_information": [ { "code": "SUP-418638", "type": "CDM" }, { "code": "C1889", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 1434.78, "maximum": 8967.35, "setting": "outpatient", "gross_charge": 8967.35, "discounted_cash": 6277.14, "payers_information": [ { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 8967.35, "10th_percentile": 8967.35, "90th_percentile": 8967.35, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8967.35, "10th_percentile": 8967.35, "90th_percentile": 8967.35, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 8967.35, "10th_percentile": 8967.35, "90th_percentile": 8967.35, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 2654.34, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 101.23, "10th_percentile": 101.23, "90th_percentile": 101.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 8967.35, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,967.35 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 8967.35, "10th_percentile": 8967.35, "90th_percentile": 8967.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $8,967.35 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 6725.51, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 6725.51, "10th_percentile": 6725.51, "90th_percentile": 6725.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 7173.88, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 7173.88, "10th_percentile": 7173.88, "90th_percentile": 7173.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 3039.93, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 3039.93, "10th_percentile": 3039.93, "90th_percentile": 3039.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 1927.98, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 1927.98, "10th_percentile": 1927.98, "90th_percentile": 1927.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 1676.89, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1676.89, "10th_percentile": 1676.89, "90th_percentile": 1676.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 7173.88, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7173.88, "10th_percentile": 7173.88, "90th_percentile": 7173.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 4062.21, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4062.21, "10th_percentile": 4062.21, "90th_percentile": 4062.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 5759.73, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 5759.73, "10th_percentile": 5759.73, "90th_percentile": 5759.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 8967.35, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 8967.35, "10th_percentile": 8967.35, "90th_percentile": 8967.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 7622.25, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 7622.25, "10th_percentile": 7622.25, "90th_percentile": 7622.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 4483.68, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4483.68, "10th_percentile": 4483.68, "90th_percentile": 4483.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 4582.32, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4582.32, "10th_percentile": 4582.32, "90th_percentile": 4582.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 5380.41, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 5380.41, "10th_percentile": 5380.41, "90th_percentile": 5380.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 6277.15, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 6277.15, "10th_percentile": 6277.15, "90th_percentile": 6277.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 6725.51, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 6725.51, "10th_percentile": 6725.51, "90th_percentile": 6725.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 4483.68, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 4483.68, "10th_percentile": 4483.68, "90th_percentile": 4483.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 5093.45, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5093.45, "10th_percentile": 5093.45, "90th_percentile": 5093.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 5093.45, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5093.45, "10th_percentile": 5093.45, "90th_percentile": 5093.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1721.73, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1721.73, "10th_percentile": 1721.73, "90th_percentile": 1721.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1721.73, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1721.73, "10th_percentile": 1721.73, "90th_percentile": 1721.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 3508.92, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3508.92, "10th_percentile": 3508.92, "90th_percentile": 3508.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 3508.92, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3508.92, "10th_percentile": 3508.92, "90th_percentile": 3508.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 1434.78, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1434.78, "10th_percentile": 1434.78, "90th_percentile": 1434.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1434.78, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1434.78, "10th_percentile": 1434.78, "90th_percentile": 1434.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1434.78, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1434.78, "10th_percentile": 1434.78, "90th_percentile": 1434.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 8967.35, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 8967.35, "10th_percentile": 8967.35, "90th_percentile": 8967.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 8967.35, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 8967.35, "10th_percentile": 8967.35, "90th_percentile": 8967.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 8967.35, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 8967.35, "10th_percentile": 8967.35, "90th_percentile": 8967.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 8967.35, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 8967.35, "10th_percentile": 8967.35, "90th_percentile": 8967.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 8967.35, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 8967.35, "10th_percentile": 8967.35, "90th_percentile": 8967.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 8967.35, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 8967.35, "10th_percentile": 8967.35, "90th_percentile": 8967.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 8967.35, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 8967.35, "10th_percentile": 8967.35, "90th_percentile": 8967.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 8967.35, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 8967.35, "10th_percentile": 8967.35, "90th_percentile": 8967.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "CAGE SPINAL SMALL 5X11X14 MM PEEK", "code_information": [ { "code": "SUP-323653", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 262.36, "maximum": 1639.74, "setting": "outpatient", "gross_charge": 1639.74, "discounted_cash": 1147.82, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 837.91, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 252.68, "10th_percentile": 252.68, "90th_percentile": 252.68, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 352.54, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 373.87, "10th_percentile": 373.87, "90th_percentile": 373.87, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 262.36, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 262.36, "10th_percentile": 262.36, "90th_percentile": 262.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 262.36, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 262.36, "10th_percentile": 262.36, "90th_percentile": 262.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 262.36, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 262.36, "10th_percentile": 262.36, "90th_percentile": 262.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 314.83, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 314.83, "10th_percentile": 314.83, "90th_percentile": 314.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 314.83, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 314.83, "10th_percentile": 314.83, "90th_percentile": 314.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 931.37, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 931.37, "10th_percentile": 931.37, "90th_percentile": 931.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 931.37, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 931.37, "10th_percentile": 931.37, "90th_percentile": 931.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 641.63, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 641.63, "10th_percentile": 641.63, "90th_percentile": 641.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 641.63, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 641.63, "10th_percentile": 641.63, "90th_percentile": 641.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 485.36, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.51, "10th_percentile": 5.51, "90th_percentile": 5.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1229.81, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1229.81, "10th_percentile": 1229.81, "90th_percentile": 1229.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1311.79, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1311.79, "10th_percentile": 1311.79, "90th_percentile": 1311.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1053.21, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1053.21, "10th_percentile": 1053.21, "90th_percentile": 1053.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1639.74, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,639.74 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1639.74, "10th_percentile": 1639.74, "90th_percentile": 1639.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,639.74 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 819.87, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 819.87, "10th_percentile": 819.87, "90th_percentile": 819.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1311.79, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1311.79, "10th_percentile": 1311.79, "90th_percentile": 1311.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 742.8, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 742.8, "10th_percentile": 742.8, "90th_percentile": 742.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 819.87, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 819.87, "10th_percentile": 819.87, "90th_percentile": 819.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1393.78, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1393.78, "10th_percentile": 1393.78, "90th_percentile": 1393.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1147.82, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1147.82, "10th_percentile": 1147.82, "90th_percentile": 1147.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 555.87, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 555.87, "10th_percentile": 555.87, "90th_percentile": 555.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1639.74, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1639.74, "10th_percentile": 1639.74, "90th_percentile": 1639.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 983.84, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 983.84, "10th_percentile": 983.84, "90th_percentile": 983.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1229.81, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1229.81, "10th_percentile": 1229.81, "90th_percentile": 1229.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 306.63, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 306.63, "10th_percentile": 306.63, "90th_percentile": 306.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1639.74, "10th_percentile": 1639.74, "90th_percentile": 1639.74, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1639.74, "10th_percentile": 1639.74, "90th_percentile": 1639.74, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1639.74, "10th_percentile": 1639.74, "90th_percentile": 1639.74, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1639.74, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1639.74, "10th_percentile": 1639.74, "90th_percentile": 1639.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1639.74, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1639.74, "10th_percentile": 1639.74, "90th_percentile": 1639.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1639.74, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1639.74, "10th_percentile": 1639.74, "90th_percentile": 1639.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1639.74, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1639.74, "10th_percentile": 1639.74, "90th_percentile": 1639.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1639.74, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1639.74, "10th_percentile": 1639.74, "90th_percentile": 1639.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1639.74, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1639.74, "10th_percentile": 1639.74, "90th_percentile": 1639.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1639.74, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1639.74, "10th_percentile": 1639.74, "90th_percentile": 1639.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1639.74, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1639.74, "10th_percentile": 1639.74, "90th_percentile": 1639.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "CAGE SPINAL W15XH9XL20MM 15DEG INTBDY ACS SHORELINE", "code_information": [ { "code": "SUP-413351", "type": "CDM" }, { "code": "C1889", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 377.14, "maximum": 2357.13, "setting": "outpatient", "gross_charge": 2357.13, "discounted_cash": 1649.99, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2357.13, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2357.13, "10th_percentile": 2357.13, "90th_percentile": 2357.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 1067.78, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1067.78, "10th_percentile": 1067.78, "90th_percentile": 1067.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2357.13, "10th_percentile": 2357.13, "90th_percentile": 2357.13, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2357.13, "10th_percentile": 2357.13, "90th_percentile": 2357.13, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2357.13, "10th_percentile": 2357.13, "90th_percentile": 2357.13, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 697.71, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 101.23, "10th_percentile": 101.23, "90th_percentile": 101.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2357.13, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,357.13 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2357.13, "10th_percentile": 2357.13, "90th_percentile": 2357.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2,357.13 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1767.85, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1767.85, "10th_percentile": 1767.85, "90th_percentile": 1767.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1885.7, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1885.7, "10th_percentile": 1885.7, "90th_percentile": 1885.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 799.07, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 799.07, "10th_percentile": 799.07, "90th_percentile": 799.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 506.78, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 506.78, "10th_percentile": 506.78, "90th_percentile": 506.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 440.78, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 440.78, "10th_percentile": 440.78, "90th_percentile": 440.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1885.7, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1885.7, "10th_percentile": 1885.7, "90th_percentile": 1885.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1513.98, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1513.98, "10th_percentile": 1513.98, "90th_percentile": 1513.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 2003.56, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 2003.56, "10th_percentile": 2003.56, "90th_percentile": 2003.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1178.57, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1178.57, "10th_percentile": 1178.57, "90th_percentile": 1178.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1204.49, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1204.49, "10th_percentile": 1204.49, "90th_percentile": 1204.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1414.28, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1414.28, "10th_percentile": 1414.28, "90th_percentile": 1414.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1649.99, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1649.99, "10th_percentile": 1649.99, "90th_percentile": 1649.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1767.85, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1767.85, "10th_percentile": 1767.85, "90th_percentile": 1767.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1178.57, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1178.57, "10th_percentile": 1178.57, "90th_percentile": 1178.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1338.85, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1338.85, "10th_percentile": 1338.85, "90th_percentile": 1338.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1338.85, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1338.85, "10th_percentile": 1338.85, "90th_percentile": 1338.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 452.57, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 452.57, "10th_percentile": 452.57, "90th_percentile": 452.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 452.57, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 452.57, "10th_percentile": 452.57, "90th_percentile": 452.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 922.34, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 922.34, "10th_percentile": 922.34, "90th_percentile": 922.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 922.34, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 922.34, "10th_percentile": 922.34, "90th_percentile": 922.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 377.14, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 377.14, "10th_percentile": 377.14, "90th_percentile": 377.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 377.14, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 377.14, "10th_percentile": 377.14, "90th_percentile": 377.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 377.14, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 377.14, "10th_percentile": 377.14, "90th_percentile": 377.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2357.13, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2357.13, "10th_percentile": 2357.13, "90th_percentile": 2357.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2357.13, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2357.13, "10th_percentile": 2357.13, "90th_percentile": 2357.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2357.13, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2357.13, "10th_percentile": 2357.13, "90th_percentile": 2357.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2357.13, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2357.13, "10th_percentile": 2357.13, "90th_percentile": 2357.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2357.13, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2357.13, "10th_percentile": 2357.13, "90th_percentile": 2357.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2357.13, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2357.13, "10th_percentile": 2357.13, "90th_percentile": 2357.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2357.13, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2357.13, "10th_percentile": 2357.13, "90th_percentile": 2357.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2357.13, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2357.13, "10th_percentile": 2357.13, "90th_percentile": 2357.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "CAGE SPINE ANT COUGAR MED 10DEG 18MM", "code_information": [ { "code": "SUP-341764", "type": "CDM" }, { "code": "C1889", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 983.85, "maximum": 6149.04, "setting": "outpatient", "gross_charge": 6149.04, "discounted_cash": 4304.33, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 6149.04, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 6149.04, "10th_percentile": 6149.04, "90th_percentile": 6149.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 2785.52, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2785.52, "10th_percentile": 2785.52, "90th_percentile": 2785.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 3142.16, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3142.16, "10th_percentile": 3142.16, "90th_percentile": 3142.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 3949.53, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 3949.53, "10th_percentile": 3949.53, "90th_percentile": 3949.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6149.04, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6149.04, "10th_percentile": 6149.04, "90th_percentile": 6149.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 6149.04, "10th_percentile": 6149.04, "90th_percentile": 6149.04, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6149.04, "10th_percentile": 6149.04, "90th_percentile": 6149.04, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6149.04, "10th_percentile": 6149.04, "90th_percentile": 6149.04, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 1820.12, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 101.23, "10th_percentile": 101.23, "90th_percentile": 101.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 6149.04, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,149.04 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 6149.04, "10th_percentile": 6149.04, "90th_percentile": 6149.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6,149.04 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 2084.52, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 2084.52, "10th_percentile": 2084.52, "90th_percentile": 2084.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 4304.33, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 4304.33, "10th_percentile": 4304.33, "90th_percentile": 4304.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 5226.68, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 5226.68, "10th_percentile": 5226.68, "90th_percentile": 5226.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 3074.52, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 3074.52, "10th_percentile": 3074.52, "90th_percentile": 3074.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 4919.23, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4919.23, "10th_percentile": 4919.23, "90th_percentile": 4919.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 4611.78, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 4611.78, "10th_percentile": 4611.78, "90th_percentile": 4611.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 1149.87, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1149.87, "10th_percentile": 1149.87, "90th_percentile": 1149.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 4611.78, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 4611.78, "10th_percentile": 4611.78, "90th_percentile": 4611.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 3689.42, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 3689.42, "10th_percentile": 3689.42, "90th_percentile": 3689.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 3074.52, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3074.52, "10th_percentile": 3074.52, "90th_percentile": 3074.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 4919.23, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 4919.23, "10th_percentile": 4919.23, "90th_percentile": 4919.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 1322.04, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 1322.04, "10th_percentile": 1322.04, "90th_percentile": 1322.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1180.62, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1180.62, "10th_percentile": 1180.62, "90th_percentile": 1180.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1180.62, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1180.62, "10th_percentile": 1180.62, "90th_percentile": 1180.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2406.12, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2406.12, "10th_percentile": 2406.12, "90th_percentile": 2406.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2406.12, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2406.12, "10th_percentile": 2406.12, "90th_percentile": 2406.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 3492.65, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3492.65, "10th_percentile": 3492.65, "90th_percentile": 3492.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 3492.65, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3492.65, "10th_percentile": 3492.65, "90th_percentile": 3492.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 983.85, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 983.85, "10th_percentile": 983.85, "90th_percentile": 983.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 983.85, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 983.85, "10th_percentile": 983.85, "90th_percentile": 983.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 983.85, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 983.85, "10th_percentile": 983.85, "90th_percentile": 983.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6149.04, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6149.04, "10th_percentile": 6149.04, "90th_percentile": 6149.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6149.04, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6149.04, "10th_percentile": 6149.04, "90th_percentile": 6149.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6149.04, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6149.04, "10th_percentile": 6149.04, "90th_percentile": 6149.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6149.04, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6149.04, "10th_percentile": 6149.04, "90th_percentile": 6149.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6149.04, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6149.04, "10th_percentile": 6149.04, "90th_percentile": 6149.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6149.04, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6149.04, "10th_percentile": 6149.04, "90th_percentile": 6149.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6149.04, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6149.04, "10th_percentile": 6149.04, "90th_percentile": 6149.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "CAGE SPINE PACIFICA 9X24X9MM PEEK OPTMA", "code_information": [ { "code": "SUP-135701", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 655.9, "maximum": 4099.36, "setting": "outpatient", "gross_charge": 4099.36, "discounted_cash": 2869.55, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 2094.77, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 252.68, "10th_percentile": 252.68, "90th_percentile": 252.68, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 881.36, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 373.87, "10th_percentile": 373.87, "90th_percentile": 373.87, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 655.9, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 655.9, "10th_percentile": 655.9, "90th_percentile": 655.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 655.9, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 655.9, "10th_percentile": 655.9, "90th_percentile": 655.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 655.9, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 655.9, "10th_percentile": 655.9, "90th_percentile": 655.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 787.08, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 787.08, "10th_percentile": 787.08, "90th_percentile": 787.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 787.08, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 787.08, "10th_percentile": 787.08, "90th_percentile": 787.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 2328.44, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2328.44, "10th_percentile": 2328.44, "90th_percentile": 2328.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 2328.44, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2328.44, "10th_percentile": 2328.44, "90th_percentile": 2328.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1604.08, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1604.08, "10th_percentile": 1604.08, "90th_percentile": 1604.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 1604.08, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1604.08, "10th_percentile": 1604.08, "90th_percentile": 1604.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 1213.41, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.51, "10th_percentile": 5.51, "90th_percentile": 5.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 3074.52, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 3074.52, "10th_percentile": 3074.52, "90th_percentile": 3074.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 3279.49, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 3279.49, "10th_percentile": 3279.49, "90th_percentile": 3279.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 2633.02, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 2633.02, "10th_percentile": 2633.02, "90th_percentile": 2633.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 4099.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $4,099.36 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 4099.36, "10th_percentile": 4099.36, "90th_percentile": 4099.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $4,099.36 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 2049.68, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2049.68, "10th_percentile": 2049.68, "90th_percentile": 2049.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 3279.49, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3279.49, "10th_percentile": 3279.49, "90th_percentile": 3279.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 1857.01, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1857.01, "10th_percentile": 1857.01, "90th_percentile": 1857.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 2049.68, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 2049.68, "10th_percentile": 2049.68, "90th_percentile": 2049.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 3484.46, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 3484.46, "10th_percentile": 3484.46, "90th_percentile": 3484.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 2869.55, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 2869.55, "10th_percentile": 2869.55, "90th_percentile": 2869.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 1389.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 1389.68, "10th_percentile": 1389.68, "90th_percentile": 1389.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 4099.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 4099.36, "10th_percentile": 4099.36, "90th_percentile": 4099.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 2459.62, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 2459.62, "10th_percentile": 2459.62, "90th_percentile": 2459.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 3074.52, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 3074.52, "10th_percentile": 3074.52, "90th_percentile": 3074.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 766.58, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 766.58, "10th_percentile": 766.58, "90th_percentile": 766.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 4099.36, "10th_percentile": 4099.36, "90th_percentile": 4099.36, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4099.36, "10th_percentile": 4099.36, "90th_percentile": 4099.36, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 4099.36, "10th_percentile": 4099.36, "90th_percentile": 4099.36, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4099.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4099.36, "10th_percentile": 4099.36, "90th_percentile": 4099.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4099.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4099.36, "10th_percentile": 4099.36, "90th_percentile": 4099.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4099.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4099.36, "10th_percentile": 4099.36, "90th_percentile": 4099.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4099.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4099.36, "10th_percentile": 4099.36, "90th_percentile": 4099.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4099.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4099.36, "10th_percentile": 4099.36, "90th_percentile": 4099.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4099.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4099.36, "10th_percentile": 4099.36, "90th_percentile": 4099.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4099.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4099.36, "10th_percentile": 4099.36, "90th_percentile": 4099.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 4099.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 4099.36, "10th_percentile": 4099.36, "90th_percentile": 4099.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "CAGE SPN INTERLAMINAR COFLEX 14MM", "code_information": [ { "code": "SUP-358216", "type": "CDM" }, { "code": "C1821", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 2049.68, "maximum": 12810.5, "setting": "outpatient", "gross_charge": 12810.5, "discounted_cash": 8967.35, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 12810.5, "10th_percentile": 12810.5, "90th_percentile": 12810.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 5012.75, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5012.75, "10th_percentile": 5012.75, "90th_percentile": 5012.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 4342.76, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 4342.76, "10th_percentile": 4342.76, "90th_percentile": 4342.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 2754.26, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 2754.26, "10th_percentile": 2754.26, "90th_percentile": 2754.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 5012.75, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5012.75, "10th_percentile": 5012.75, "90th_percentile": 5012.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 2459.62, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2459.62, "10th_percentile": 2459.62, "90th_percentile": 2459.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 10248.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 10248.4, "10th_percentile": 10248.4, "90th_percentile": 10248.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 7276.36, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7276.36, "10th_percentile": 7276.36, "90th_percentile": 7276.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 2049.68, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2049.68, "10th_percentile": 2049.68, "90th_percentile": 2049.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 2049.68, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2049.68, "10th_percentile": 2049.68, "90th_percentile": 2049.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 2049.68, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2049.68, "10th_percentile": 2049.68, "90th_percentile": 2049.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12810.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12810.5, "10th_percentile": 12810.5, "90th_percentile": 12810.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 12810.5, "10th_percentile": 12810.5, "90th_percentile": 12810.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 12810.5, "10th_percentile": 12810.5, "90th_percentile": 12810.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 12810.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 12810.5, "10th_percentile": 12810.5, "90th_percentile": 12810.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 6546.17, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6546.17, "10th_percentile": 6546.17, "90th_percentile": 6546.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 5803.16, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5803.16, "10th_percentile": 5803.16, "90th_percentile": 5803.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 10248.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10248.4, "10th_percentile": 10248.4, "90th_percentile": 10248.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 3791.91, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3791.91, "10th_percentile": 3791.91, "90th_percentile": 3791.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 2395.56, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2395.56, "10th_percentile": 2395.56, "90th_percentile": 2395.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 10888.93, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 10888.93, "10th_percentile": 10888.93, "90th_percentile": 10888.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 8228.18, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 8228.18, "10th_percentile": 8228.18, "90th_percentile": 8228.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 6405.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 6405.25, "10th_percentile": 6405.25, "90th_percentile": 6405.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 9607.88, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 9607.88, "10th_percentile": 9607.88, "90th_percentile": 9607.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 8967.35, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 8967.35, "10th_percentile": 8967.35, "90th_percentile": 8967.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 6405.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 6405.25, "10th_percentile": 6405.25, "90th_percentile": 6405.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 7686.3, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 7686.3, "10th_percentile": 7686.3, "90th_percentile": 7686.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 9607.88, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 9607.88, "10th_percentile": 9607.88, "90th_percentile": 9607.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 12810.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $12,810.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 12810.5, "10th_percentile": 12810.5, "90th_percentile": 12810.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $12,810.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 2459.62, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2459.62, "10th_percentile": 2459.62, "90th_percentile": 2459.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 7276.36, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 7276.36, "10th_percentile": 7276.36, "90th_percentile": 7276.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12810.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12810.5, "10th_percentile": 12810.5, "90th_percentile": 12810.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12810.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12810.5, "10th_percentile": 12810.5, "90th_percentile": 12810.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12810.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12810.5, "10th_percentile": 12810.5, "90th_percentile": 12810.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12810.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12810.5, "10th_percentile": 12810.5, "90th_percentile": 12810.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12810.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12810.5, "10th_percentile": 12810.5, "90th_percentile": 12810.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12810.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12810.5, "10th_percentile": 12810.5, "90th_percentile": 12810.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 12810.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 12810.5, "10th_percentile": 12810.5, "90th_percentile": 12810.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "CAGE SPN POST LUMB 6 DEG 7X23X9MM TRI", "code_information": [ { "code": "SUP-366386", "type": "CDM" }, { "code": "C1889", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 1188.81, "maximum": 7430.09, "setting": "outpatient", "gross_charge": 7430.09, "discounted_cash": 5201.06, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7430.09, "10th_percentile": 7430.09, "90th_percentile": 7430.09, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 7430.09, "10th_percentile": 7430.09, "90th_percentile": 7430.09, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 7430.09, "10th_percentile": 7430.09, "90th_percentile": 7430.09, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 7430.09, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $7,430.09 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 7430.09, "10th_percentile": 7430.09, "90th_percentile": 7430.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $7,430.09 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 5944.07, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5944.07, "10th_percentile": 5944.07, "90th_percentile": 5944.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 5572.57, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 5572.57, "10th_percentile": 5572.57, "90th_percentile": 5572.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 3715.05, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 3715.05, "10th_percentile": 3715.05, "90th_percentile": 3715.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 1597.47, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 1597.47, "10th_percentile": 1597.47, "90th_percentile": 1597.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 5201.06, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 5201.06, "10th_percentile": 5201.06, "90th_percentile": 5201.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 1389.43, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1389.43, "10th_percentile": 1389.43, "90th_percentile": 1389.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 7430.09, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 7430.09, "10th_percentile": 7430.09, "90th_percentile": 7430.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 4458.05, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 4458.05, "10th_percentile": 4458.05, "90th_percentile": 4458.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 3365.83, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3365.83, "10th_percentile": 3365.83, "90th_percentile": 3365.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 3796.78, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3796.78, "10th_percentile": 3796.78, "90th_percentile": 3796.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 3715.05, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3715.05, "10th_percentile": 3715.05, "90th_percentile": 3715.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 4772.35, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 4772.35, "10th_percentile": 4772.35, "90th_percentile": 4772.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 6315.58, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 6315.58, "10th_percentile": 6315.58, "90th_percentile": 6315.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 2518.8, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 2518.8, "10th_percentile": 2518.8, "90th_percentile": 2518.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 5944.07, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 5944.07, "10th_percentile": 5944.07, "90th_percentile": 5944.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 5572.57, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 5572.57, "10th_percentile": 5572.57, "90th_percentile": 5572.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 2199.31, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 101.23, "10th_percentile": 101.23, "90th_percentile": 101.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2907.39, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2907.39, "10th_percentile": 2907.39, "90th_percentile": 2907.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2907.39, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2907.39, "10th_percentile": 2907.39, "90th_percentile": 2907.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 4220.29, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4220.29, "10th_percentile": 4220.29, "90th_percentile": 4220.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 4220.29, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4220.29, "10th_percentile": 4220.29, "90th_percentile": 4220.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1426.58, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1426.58, "10th_percentile": 1426.58, "90th_percentile": 1426.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1426.58, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1426.58, "10th_percentile": 1426.58, "90th_percentile": 1426.58, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 1188.81, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1188.81, "10th_percentile": 1188.81, "90th_percentile": 1188.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 1188.81, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1188.81, "10th_percentile": 1188.81, "90th_percentile": 1188.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1188.81, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1188.81, "10th_percentile": 1188.81, "90th_percentile": 1188.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7430.09, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7430.09, "10th_percentile": 7430.09, "90th_percentile": 7430.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7430.09, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7430.09, "10th_percentile": 7430.09, "90th_percentile": 7430.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7430.09, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7430.09, "10th_percentile": 7430.09, "90th_percentile": 7430.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7430.09, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7430.09, "10th_percentile": 7430.09, "90th_percentile": 7430.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7430.09, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7430.09, "10th_percentile": 7430.09, "90th_percentile": 7430.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7430.09, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7430.09, "10th_percentile": 7430.09, "90th_percentile": 7430.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7430.09, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7430.09, "10th_percentile": 7430.09, "90th_percentile": 7430.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 7430.09, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 7430.09, "10th_percentile": 7430.09, "90th_percentile": 7430.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "CAGE TITAN 11X35X7MM PRLLL", "code_information": [ { "code": "SUP-335032", "type": "CDM" }, { "code": "C1889", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 934.65, "maximum": 5841.59, "setting": "outpatient", "gross_charge": 5841.59, "discounted_cash": 4089.11, "payers_information": [ { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 5841.59, "10th_percentile": 5841.59, "90th_percentile": 5841.59, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5841.59, "10th_percentile": 5841.59, "90th_percentile": 5841.59, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 5841.59, "10th_percentile": 5841.59, "90th_percentile": 5841.59, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 1729.11, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 101.23, "10th_percentile": 101.23, "90th_percentile": 101.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 5841.59, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $5,841.59 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 5841.59, "10th_percentile": 5841.59, "90th_percentile": 5841.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $5,841.59 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 4381.19, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 4381.19, "10th_percentile": 4381.19, "90th_percentile": 4381.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 4673.27, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 4673.27, "10th_percentile": 4673.27, "90th_percentile": 4673.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 1980.3, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 1980.3, "10th_percentile": 1980.3, "90th_percentile": 1980.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 1255.94, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 1255.94, "10th_percentile": 1255.94, "90th_percentile": 1255.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 1092.38, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1092.38, "10th_percentile": 1092.38, "90th_percentile": 1092.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 4673.27, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4673.27, "10th_percentile": 4673.27, "90th_percentile": 4673.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 2646.24, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2646.24, "10th_percentile": 2646.24, "90th_percentile": 2646.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 3752.05, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 3752.05, "10th_percentile": 3752.05, "90th_percentile": 3752.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 5841.59, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 5841.59, "10th_percentile": 5841.59, "90th_percentile": 5841.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 4965.35, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 4965.35, "10th_percentile": 4965.35, "90th_percentile": 4965.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 2920.8, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2920.8, "10th_percentile": 2920.8, "90th_percentile": 2920.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 2985.05, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2985.05, "10th_percentile": 2985.05, "90th_percentile": 2985.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 3504.95, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 3504.95, "10th_percentile": 3504.95, "90th_percentile": 3504.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 4089.11, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 4089.11, "10th_percentile": 4089.11, "90th_percentile": 4089.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 4381.19, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 4381.19, "10th_percentile": 4381.19, "90th_percentile": 4381.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 2920.8, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 2920.8, "10th_percentile": 2920.8, "90th_percentile": 2920.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 3318.02, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3318.02, "10th_percentile": 3318.02, "90th_percentile": 3318.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 3318.02, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3318.02, "10th_percentile": 3318.02, "90th_percentile": 3318.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1121.59, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1121.59, "10th_percentile": 1121.59, "90th_percentile": 1121.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1121.59, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1121.59, "10th_percentile": 1121.59, "90th_percentile": 1121.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2285.81, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2285.81, "10th_percentile": 2285.81, "90th_percentile": 2285.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2285.81, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2285.81, "10th_percentile": 2285.81, "90th_percentile": 2285.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 934.65, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 934.65, "10th_percentile": 934.65, "90th_percentile": 934.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 934.65, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 934.65, "10th_percentile": 934.65, "90th_percentile": 934.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 934.65, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 934.65, "10th_percentile": 934.65, "90th_percentile": 934.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5841.59, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5841.59, "10th_percentile": 5841.59, "90th_percentile": 5841.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5841.59, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5841.59, "10th_percentile": 5841.59, "90th_percentile": 5841.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5841.59, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5841.59, "10th_percentile": 5841.59, "90th_percentile": 5841.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5841.59, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5841.59, "10th_percentile": 5841.59, "90th_percentile": 5841.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5841.59, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5841.59, "10th_percentile": 5841.59, "90th_percentile": 5841.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5841.59, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5841.59, "10th_percentile": 5841.59, "90th_percentile": 5841.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5841.59, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5841.59, "10th_percentile": 5841.59, "90th_percentile": 5841.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 5841.59, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 5841.59, "10th_percentile": 5841.59, "90th_percentile": 5841.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "CALCITRIOL 0.25 MCG ORAL CAP", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-9350", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "64380-0723-04", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.89, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.89, "10th_percentile": 0.89, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.89, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.89, "10th_percentile": 0.89, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1.7, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1.7, "10th_percentile": 1.7, "90th_percentile": 1.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1.2, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1.2, "10th_percentile": 1.2, "90th_percentile": 1.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1.28, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1.28, "10th_percentile": 1.28, "90th_percentile": 1.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1.4, "10th_percentile": 1.4, "90th_percentile": 1.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.29, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.29, "10th_percentile": 0.29, "90th_percentile": 0.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 0.91, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.91, "10th_percentile": 0.91, "90th_percentile": 0.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1.02, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.02, "10th_percentile": 1.02, "90th_percentile": 1.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.59, "10th_percentile": 0.59, "90th_percentile": 0.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.28, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.28, "10th_percentile": 0.28, "90th_percentile": 0.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.37, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.37, "10th_percentile": 0.37, "90th_percentile": 0.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.68, "10th_percentile": 0.68, "90th_percentile": 0.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.43, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.34, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.34, "10th_percentile": 0.34, "90th_percentile": 0.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "CALCIUM CARBONATE 200 MG CALCIUM (500 MG) ORAL CHEW", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-9385", "type": "CDM" }, { "code": "J8499", "type": "HCPCS" }, { "code": "0637", "type": "RC" }, { "code": "00536-1007-15", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.32, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.32, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.32, "10th_percentile": 0.32, "90th_percentile": 0.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.32, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.32, "10th_percentile": 0.32, "90th_percentile": 0.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.38, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.38, "10th_percentile": 0.38, "90th_percentile": 0.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1.7, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1.7, "10th_percentile": 1.7, "90th_percentile": 1.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1.4, "10th_percentile": 1.4, "90th_percentile": 1.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1.28, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1.28, "10th_percentile": 1.28, "90th_percentile": 1.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Drugs/Agents Default; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.68, "10th_percentile": 0.68, "90th_percentile": 0.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.43, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.38, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.38, "10th_percentile": 0.38, "90th_percentile": 0.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.32, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.32, "10th_percentile": 0.32, "90th_percentile": 0.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "CANISTER NPWT INFOVAC 1000ML", "code_information": [ { "code": "SUP-360207", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 18.11, "maximum": 129.43, "setting": "outpatient", "gross_charge": 129.43, "discounted_cash": 90.6, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 50.65, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 50.65, "10th_percentile": 50.65, "90th_percentile": 50.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 50.65, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 50.65, "10th_percentile": 50.65, "90th_percentile": 50.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 57.31, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 57.31, "10th_percentile": 57.31, "90th_percentile": 57.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 57.31, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 57.31, "10th_percentile": 57.31, "90th_percentile": 57.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 73.52, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 73.52, "10th_percentile": 73.52, "90th_percentile": 73.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 73.52, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 73.52, "10th_percentile": 73.52, "90th_percentile": 73.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 97.07, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 97.07, "10th_percentile": 97.07, "90th_percentile": 97.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 27.83, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 27.83, "10th_percentile": 27.83, "90th_percentile": 27.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 43.88, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 43.88, "10th_percentile": 43.88, "90th_percentile": 43.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 90.6, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 90.6, "10th_percentile": 90.6, "90th_percentile": 90.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 97.07, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 97.07, "10th_percentile": 97.07, "90th_percentile": 97.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 64.72, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 64.72, "10th_percentile": 64.72, "90th_percentile": 64.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 64.72, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 64.72, "10th_percentile": 64.72, "90th_percentile": 64.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 103.54, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 103.54, "10th_percentile": 103.54, "90th_percentile": 103.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 77.66, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 77.66, "10th_percentile": 77.66, "90th_percentile": 77.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 83.13, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 83.13, "10th_percentile": 83.13, "90th_percentile": 83.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 110.02, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 110.02, "10th_percentile": 110.02, "90th_percentile": 110.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 58.63, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 58.63, "10th_percentile": 58.63, "90th_percentile": 58.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 66.14, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 66.14, "10th_percentile": 66.14, "90th_percentile": 66.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 129.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 129.43, "10th_percentile": 129.43, "90th_percentile": 129.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 24.2, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 24.2, "10th_percentile": 24.2, "90th_percentile": 24.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 103.54, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 103.54, "10th_percentile": 103.54, "90th_percentile": 103.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 38.31, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.31, "10th_percentile": 38.31, "90th_percentile": 38.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 129.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $129.43 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 129.43, "10th_percentile": 129.43, "90th_percentile": 129.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $129.43 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 21.91, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 21.91, "10th_percentile": 21.91, "90th_percentile": 21.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 18.11, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18.11, "10th_percentile": 18.11, "90th_percentile": 18.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 18.47, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18.47, "10th_percentile": 18.47, "90th_percentile": 18.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 129.43, "10th_percentile": 129.43, "90th_percentile": 129.43, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 129.43, "10th_percentile": 129.43, "90th_percentile": 129.43, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 129.43, "10th_percentile": 129.43, "90th_percentile": 129.43, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 129.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 129.43, "10th_percentile": 129.43, "90th_percentile": 129.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 129.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 129.43, "10th_percentile": 129.43, "90th_percentile": 129.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 129.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 129.43, "10th_percentile": 129.43, "90th_percentile": 129.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 129.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 129.43, "10th_percentile": 129.43, "90th_percentile": 129.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 129.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 129.43, "10th_percentile": 129.43, "90th_percentile": 129.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 129.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 129.43, "10th_percentile": 129.43, "90th_percentile": 129.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 129.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 129.43, "10th_percentile": 129.43, "90th_percentile": 129.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 129.43, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 129.43, "10th_percentile": 129.43, "90th_percentile": 129.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "CANN CONNECTING SCRW F TROCHANTERIC FIXATION NAILS", "code_information": [ { "code": "SUP-377148", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "minimum": 82.81, "maximum": 517.54, "setting": "outpatient", "gross_charge": 517.54, "discounted_cash": 362.28, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 111.27, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 373.87, "10th_percentile": 373.87, "90th_percentile": 373.87, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 82.81, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 82.81, "10th_percentile": 82.81, "90th_percentile": 82.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 82.81, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 82.81, "10th_percentile": 82.81, "90th_percentile": 82.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 82.81, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 82.81, "10th_percentile": 82.81, "90th_percentile": 82.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 293.96, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 293.96, "10th_percentile": 293.96, "90th_percentile": 293.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 293.96, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 293.96, "10th_percentile": 293.96, "90th_percentile": 293.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 99.37, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 99.37, "10th_percentile": 99.37, "90th_percentile": 99.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 99.37, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 99.37, "10th_percentile": 99.37, "90th_percentile": 99.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 202.51, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 202.51, "10th_percentile": 202.51, "90th_percentile": 202.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 202.51, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 202.51, "10th_percentile": 202.51, "90th_percentile": 202.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 153.19, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.51, "10th_percentile": 5.51, "90th_percentile": 5.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 310.52, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 310.52, "10th_percentile": 310.52, "90th_percentile": 310.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 258.77, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 258.77, "10th_percentile": 258.77, "90th_percentile": 258.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 414.03, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 414.03, "10th_percentile": 414.03, "90th_percentile": 414.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 517.54, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $517.54 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 517.54, "10th_percentile": 517.54, "90th_percentile": 517.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $517.54 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 414.03, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 414.03, "10th_percentile": 414.03, "90th_percentile": 414.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 439.91, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 439.91, "10th_percentile": 439.91, "90th_percentile": 439.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 388.16, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 388.16, "10th_percentile": 388.16, "90th_percentile": 388.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 258.77, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 258.77, "10th_percentile": 258.77, "90th_percentile": 258.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 362.28, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 362.28, "10th_percentile": 362.28, "90th_percentile": 362.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 96.78, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 96.78, "10th_percentile": 96.78, "90th_percentile": 96.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 175.45, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 175.45, "10th_percentile": 175.45, "90th_percentile": 175.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 388.16, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 388.16, "10th_percentile": 388.16, "90th_percentile": 388.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 517.54, "10th_percentile": 517.54, "90th_percentile": 517.54, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 517.54, "10th_percentile": 517.54, "90th_percentile": 517.54, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 517.54, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 517.54, "10th_percentile": 517.54, "90th_percentile": 517.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 517.54, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 517.54, "10th_percentile": 517.54, "90th_percentile": 517.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 517.54, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 517.54, "10th_percentile": 517.54, "90th_percentile": 517.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 517.54, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 517.54, "10th_percentile": 517.54, "90th_percentile": 517.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 517.54, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 517.54, "10th_percentile": 517.54, "90th_percentile": 517.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 517.54, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 517.54, "10th_percentile": 517.54, "90th_percentile": 517.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 517.54, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 517.54, "10th_percentile": 517.54, "90th_percentile": 517.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 264.46, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 252.68, "10th_percentile": 252.68, "90th_percentile": 252.68, "count": "1 through 10", "methodology": "percent of total billed charges" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 517.54, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 517.54, "10th_percentile": 517.54, "90th_percentile": 517.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 332.42, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 332.42, "10th_percentile": 332.42, "90th_percentile": 332.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 234.45, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 234.45, "10th_percentile": 234.45, "90th_percentile": 234.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 517.54, "10th_percentile": 517.54, "90th_percentile": 517.54, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 517.54, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 517.54, "10th_percentile": 517.54, "90th_percentile": 517.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "CANN VEN SNGL RT. METAL 24 FR", "code_information": [ { "code": "SUP-305470", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 9.67, "maximum": 69.12, "setting": "outpatient", "gross_charge": 69.12, "discounted_cash": 48.38, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 27.05, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 27.05, "10th_percentile": 27.05, "90th_percentile": 27.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 27.05, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 27.05, "10th_percentile": 27.05, "90th_percentile": 27.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 30.61, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 30.61, "10th_percentile": 30.61, "90th_percentile": 30.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 30.61, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 30.61, "10th_percentile": 30.61, "90th_percentile": 30.61, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 39.26, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.26, "10th_percentile": 39.26, "90th_percentile": 39.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 39.26, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.26, "10th_percentile": 39.26, "90th_percentile": 39.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 51.84, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 51.84, "10th_percentile": 51.84, "90th_percentile": 51.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 14.86, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 14.86, "10th_percentile": 14.86, "90th_percentile": 14.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 23.43, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 23.43, "10th_percentile": 23.43, "90th_percentile": 23.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 48.38, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 48.38, "10th_percentile": 48.38, "90th_percentile": 48.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 51.84, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 51.84, "10th_percentile": 51.84, "90th_percentile": 51.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 34.56, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 34.56, "10th_percentile": 34.56, "90th_percentile": 34.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 34.56, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 34.56, "10th_percentile": 34.56, "90th_percentile": 34.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 55.3, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 55.3, "10th_percentile": 55.3, "90th_percentile": 55.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 41.47, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 41.47, "10th_percentile": 41.47, "90th_percentile": 41.47, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 44.4, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 44.4, "10th_percentile": 44.4, "90th_percentile": 44.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 58.75, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 58.75, "10th_percentile": 58.75, "90th_percentile": 58.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 12.93, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.93, "10th_percentile": 12.93, "90th_percentile": 12.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 55.3, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 55.3, "10th_percentile": 55.3, "90th_percentile": 55.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 20.46, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 20.46, "10th_percentile": 20.46, "90th_percentile": 20.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 69.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $69.12 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 69.12, "10th_percentile": 69.12, "90th_percentile": 69.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $69.12 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 11.7, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.7, "10th_percentile": 11.7, "90th_percentile": 11.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 9.67, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.67, "10th_percentile": 9.67, "90th_percentile": 9.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 9.86, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.86, "10th_percentile": 9.86, "90th_percentile": 9.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 69.12, "10th_percentile": 69.12, "90th_percentile": 69.12, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 69.12, "10th_percentile": 69.12, "90th_percentile": 69.12, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 69.12, "10th_percentile": 69.12, "90th_percentile": 69.12, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 69.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 69.12, "10th_percentile": 69.12, "90th_percentile": 69.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 69.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 69.12, "10th_percentile": 69.12, "90th_percentile": 69.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 69.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 69.12, "10th_percentile": 69.12, "90th_percentile": 69.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 69.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 69.12, "10th_percentile": 69.12, "90th_percentile": 69.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 69.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 69.12, "10th_percentile": 69.12, "90th_percentile": 69.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 69.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 69.12, "10th_percentile": 69.12, "90th_percentile": 69.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 69.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 69.12, "10th_percentile": 69.12, "90th_percentile": 69.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 69.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 69.12, "10th_percentile": 69.12, "90th_percentile": 69.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 69.12, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 69.12, "10th_percentile": 69.12, "90th_percentile": 69.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 31.31, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 31.31, "10th_percentile": 31.31, "90th_percentile": 31.31, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 35.32, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 35.32, "10th_percentile": 35.32, "90th_percentile": 35.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." } ] } ] }, { "description": "CANNISTER DRAINAGE WOUND INFOVAC 500ML W/GEL 5/CS M82750635S", "code_information": [ { "code": "SUP-316051", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 11.94, "maximum": 85.38, "setting": "outpatient", "gross_charge": 85.38, "discounted_cash": 59.77, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 33.41, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33.41, "10th_percentile": 33.41, "90th_percentile": 33.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 14.45, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.45, "10th_percentile": 14.45, "90th_percentile": 14.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 12.18, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.18, "10th_percentile": 12.18, "90th_percentile": 12.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 11.94, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.94, "10th_percentile": 11.94, "90th_percentile": 11.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 37.81, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 37.81, "10th_percentile": 37.81, "90th_percentile": 37.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 85.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $85.38 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 85.38, "10th_percentile": 85.38, "90th_percentile": 85.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $85.38 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 28.94, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 28.94, "10th_percentile": 28.94, "90th_percentile": 28.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 18.36, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 18.36, "10th_percentile": 18.36, "90th_percentile": 18.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 64.04, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 64.04, "10th_percentile": 64.04, "90th_percentile": 64.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 64.04, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 64.04, "10th_percentile": 64.04, "90th_percentile": 64.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 33.41, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33.41, "10th_percentile": 33.41, "90th_percentile": 33.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 42.69, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 42.69, "10th_percentile": 42.69, "90th_percentile": 42.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 37.81, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 37.81, "10th_percentile": 37.81, "90th_percentile": 37.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 68.3, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 68.3, "10th_percentile": 68.3, "90th_percentile": 68.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 15.97, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15.97, "10th_percentile": 15.97, "90th_percentile": 15.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 25.27, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.27, "10th_percentile": 25.27, "90th_percentile": 25.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 68.3, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 68.3, "10th_percentile": 68.3, "90th_percentile": 68.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 48.5, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 48.5, "10th_percentile": 48.5, "90th_percentile": 48.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 48.5, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 48.5, "10th_percentile": 48.5, "90th_percentile": 48.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 85.38, "10th_percentile": 85.38, "90th_percentile": 85.38, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 85.38, "10th_percentile": 85.38, "90th_percentile": 85.38, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 85.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 85.38, "10th_percentile": 85.38, "90th_percentile": 85.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 85.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 85.38, "10th_percentile": 85.38, "90th_percentile": 85.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 85.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 85.38, "10th_percentile": 85.38, "90th_percentile": 85.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 85.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 85.38, "10th_percentile": 85.38, "90th_percentile": 85.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 72.57, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 72.57, "10th_percentile": 72.57, "90th_percentile": 72.57, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 54.84, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 54.84, "10th_percentile": 54.84, "90th_percentile": 54.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 42.69, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 42.69, "10th_percentile": 42.69, "90th_percentile": 42.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 59.77, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 59.77, "10th_percentile": 59.77, "90th_percentile": 59.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 51.23, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 51.23, "10th_percentile": 51.23, "90th_percentile": 51.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 85.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 85.38, "10th_percentile": 85.38, "90th_percentile": 85.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 38.68, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 38.68, "10th_percentile": 38.68, "90th_percentile": 38.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 43.63, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 43.63, "10th_percentile": 43.63, "90th_percentile": 43.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 85.38, "10th_percentile": 85.38, "90th_percentile": 85.38, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 85.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 85.38, "10th_percentile": 85.38, "90th_percentile": 85.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 85.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 85.38, "10th_percentile": 85.38, "90th_percentile": 85.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 85.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 85.38, "10th_percentile": 85.38, "90th_percentile": 85.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 85.38, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 85.38, "10th_percentile": 85.38, "90th_percentile": 85.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "CANNULA FT TWIST 5.75X7.0CM AR-6560", "code_information": [ { "code": "SUP-124300", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 8.38, "maximum": 59.88, "setting": "outpatient", "gross_charge": 59.88, "discounted_cash": 41.92, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 10.14, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 10.14, "10th_percentile": 10.14, "90th_percentile": 10.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 26.51, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 26.51, "10th_percentile": 26.51, "90th_percentile": 26.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 23.43, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 23.43, "10th_percentile": 23.43, "90th_percentile": 23.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 8.54, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.54, "10th_percentile": 8.54, "90th_percentile": 8.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 8.38, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.38, "10th_percentile": 8.38, "90th_percentile": 8.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 59.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $59.88 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 59.88, "10th_percentile": 59.88, "90th_percentile": 59.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $59.88 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 50.9, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 50.9, "10th_percentile": 50.9, "90th_percentile": 50.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 38.46, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 38.46, "10th_percentile": 38.46, "90th_percentile": 38.46, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 29.94, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 29.94, "10th_percentile": 29.94, "90th_percentile": 29.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 20.3, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 20.3, "10th_percentile": 20.3, "90th_percentile": 20.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 41.92, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 41.92, "10th_percentile": 41.92, "90th_percentile": 41.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 44.91, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 44.91, "10th_percentile": 44.91, "90th_percentile": 44.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 26.51, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 26.51, "10th_percentile": 26.51, "90th_percentile": 26.51, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 29.94, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 29.94, "10th_percentile": 29.94, "90th_percentile": 29.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 47.9, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 47.9, "10th_percentile": 47.9, "90th_percentile": 47.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 35.93, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 35.93, "10th_percentile": 35.93, "90th_percentile": 35.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 12.87, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 12.87, "10th_percentile": 12.87, "90th_percentile": 12.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 23.43, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 23.43, "10th_percentile": 23.43, "90th_percentile": 23.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 44.91, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 44.91, "10th_percentile": 44.91, "90th_percentile": 44.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 17.72, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 17.72, "10th_percentile": 17.72, "90th_percentile": 17.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 11.2, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.2, "10th_percentile": 11.2, "90th_percentile": 11.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 47.9, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 47.9, "10th_percentile": 47.9, "90th_percentile": 47.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 59.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 59.88, "10th_percentile": 59.88, "90th_percentile": 59.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 27.13, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 27.13, "10th_percentile": 27.13, "90th_percentile": 27.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 30.6, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 30.6, "10th_percentile": 30.6, "90th_percentile": 30.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 34.01, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 34.01, "10th_percentile": 34.01, "90th_percentile": 34.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 34.01, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 34.01, "10th_percentile": 34.01, "90th_percentile": 34.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 59.88, "10th_percentile": 59.88, "90th_percentile": 59.88, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 59.88, "10th_percentile": 59.88, "90th_percentile": 59.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 59.88, "10th_percentile": 59.88, "90th_percentile": 59.88, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 59.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 59.88, "10th_percentile": 59.88, "90th_percentile": 59.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 59.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 59.88, "10th_percentile": 59.88, "90th_percentile": 59.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 59.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 59.88, "10th_percentile": 59.88, "90th_percentile": 59.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 59.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 59.88, "10th_percentile": 59.88, "90th_percentile": 59.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 59.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 59.88, "10th_percentile": 59.88, "90th_percentile": 59.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 59.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 59.88, "10th_percentile": 59.88, "90th_percentile": 59.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 59.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 59.88, "10th_percentile": 59.88, "90th_percentile": 59.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 59.88, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 59.88, "10th_percentile": 59.88, "90th_percentile": 59.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "CANNULA NOMOLINE LH NASAL CO2 ADULT W/O2 (SUB FOR 250274)", "code_information": [ { "code": "SUP-416408", "type": "CDM" }, { "code": "27103350", "type": "LOCAL" }, { "code": "0271", "type": "RC" } ], "standard_charges": [ { "minimum": 4.15, "maximum": 29.65, "setting": "outpatient", "gross_charge": 29.65, "discounted_cash": 20.75, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 29.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 29.65, "10th_percentile": 29.65, "90th_percentile": 29.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 19.04, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 19.04, "10th_percentile": 19.04, "90th_percentile": 19.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 15.15, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15.15, "10th_percentile": 15.15, "90th_percentile": 15.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 13.43, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.43, "10th_percentile": 13.43, "90th_percentile": 13.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 29.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 29.65, "10th_percentile": 29.65, "90th_percentile": 29.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 29.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 29.65, "10th_percentile": 29.65, "90th_percentile": 29.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 29.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 29.65, "10th_percentile": 29.65, "90th_percentile": 29.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 29.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 29.65, "10th_percentile": 29.65, "90th_percentile": 29.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 29.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 29.65, "10th_percentile": 29.65, "90th_percentile": 29.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 29.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 29.65, "10th_percentile": 29.65, "90th_percentile": 29.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 29.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 29.65, "10th_percentile": 29.65, "90th_percentile": 29.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 29.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 29.65, "10th_percentile": 29.65, "90th_percentile": 29.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 11.6, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.6, "10th_percentile": 11.6, "90th_percentile": 11.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 11.6, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.6, "10th_percentile": 11.6, "90th_percentile": 11.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 16.84, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.84, "10th_percentile": 16.84, "90th_percentile": 16.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 16.84, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.84, "10th_percentile": 16.84, "90th_percentile": 16.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 13.13, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.13, "10th_percentile": 13.13, "90th_percentile": 13.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 13.13, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.13, "10th_percentile": 13.13, "90th_percentile": 13.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 5.54, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.54, "10th_percentile": 5.54, "90th_percentile": 5.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 22.24, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 22.24, "10th_percentile": 22.24, "90th_percentile": 22.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 29.65, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $29.65 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 29.65, "10th_percentile": 29.65, "90th_percentile": 29.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $29.65 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 5.02, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.02, "10th_percentile": 5.02, "90th_percentile": 5.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 4.23, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.23, "10th_percentile": 4.23, "90th_percentile": 4.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 4.15, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.15, "10th_percentile": 4.15, "90th_percentile": 4.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 17.79, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 17.79, "10th_percentile": 17.79, "90th_percentile": 17.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 20.76, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 20.76, "10th_percentile": 20.76, "90th_percentile": 20.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 25.2, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 25.2, "10th_percentile": 25.2, "90th_percentile": 25.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 22.24, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 22.24, "10th_percentile": 22.24, "90th_percentile": 22.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 14.83, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 14.83, "10th_percentile": 14.83, "90th_percentile": 14.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 23.72, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 23.72, "10th_percentile": 23.72, "90th_percentile": 23.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 8.78, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 8.78, "10th_percentile": 8.78, "90th_percentile": 8.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 14.83, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.83, "10th_percentile": 14.83, "90th_percentile": 14.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 10.05, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 10.05, "10th_percentile": 10.05, "90th_percentile": 10.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 6.37, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 6.37, "10th_percentile": 6.37, "90th_percentile": 6.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 23.72, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 23.72, "10th_percentile": 23.72, "90th_percentile": 23.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 29.65, "10th_percentile": 29.65, "90th_percentile": 29.65, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 29.65, "10th_percentile": 29.65, "90th_percentile": 29.65, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 29.65, "10th_percentile": 29.65, "90th_percentile": 29.65, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "CANNULA OPTH 11MM 27GA ANG AC NDL 8065441720", "code_information": [ { "code": "SUP-413560", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 4.45, "maximum": 31.81, "setting": "outpatient", "gross_charge": 31.81, "discounted_cash": 22.27, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 18.07, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18.07, "10th_percentile": 18.07, "90th_percentile": 18.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 6.84, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 6.84, "10th_percentile": 6.84, "90th_percentile": 6.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 10.78, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 10.78, "10th_percentile": 10.78, "90th_percentile": 10.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 31.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 31.81, "10th_percentile": 31.81, "90th_percentile": 31.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 5.39, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.39, "10th_percentile": 5.39, "90th_percentile": 5.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 14.09, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.09, "10th_percentile": 14.09, "90th_percentile": 14.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 12.45, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.45, "10th_percentile": 12.45, "90th_percentile": 12.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 4.54, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.54, "10th_percentile": 4.54, "90th_percentile": 4.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 4.45, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.45, "10th_percentile": 4.45, "90th_percentile": 4.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 31.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $31.81 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 31.81, "10th_percentile": 31.81, "90th_percentile": 31.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $31.81 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 27.04, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 27.04, "10th_percentile": 27.04, "90th_percentile": 27.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 20.43, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 20.43, "10th_percentile": 20.43, "90th_percentile": 20.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 15.91, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 15.91, "10th_percentile": 15.91, "90th_percentile": 15.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 22.27, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 22.27, "10th_percentile": 22.27, "90th_percentile": 22.27, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 23.86, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 23.86, "10th_percentile": 23.86, "90th_percentile": 23.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 14.09, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.09, "10th_percentile": 14.09, "90th_percentile": 14.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 15.91, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 15.91, "10th_percentile": 15.91, "90th_percentile": 15.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 25.45, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 25.45, "10th_percentile": 25.45, "90th_percentile": 25.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 19.09, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 19.09, "10th_percentile": 19.09, "90th_percentile": 19.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 12.45, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.45, "10th_percentile": 12.45, "90th_percentile": 12.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 23.86, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 23.86, "10th_percentile": 23.86, "90th_percentile": 23.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 9.42, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.42, "10th_percentile": 9.42, "90th_percentile": 9.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 5.95, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.95, "10th_percentile": 5.95, "90th_percentile": 5.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 25.45, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.45, "10th_percentile": 25.45, "90th_percentile": 25.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 31.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 31.81, "10th_percentile": 31.81, "90th_percentile": 31.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 14.41, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.41, "10th_percentile": 14.41, "90th_percentile": 14.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 16.25, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 16.25, "10th_percentile": 16.25, "90th_percentile": 16.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 18.07, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 18.07, "10th_percentile": 18.07, "90th_percentile": 18.07, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 31.81, "10th_percentile": 31.81, "90th_percentile": 31.81, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 31.81, "10th_percentile": 31.81, "90th_percentile": 31.81, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 31.81, "10th_percentile": 31.81, "90th_percentile": 31.81, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 31.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 31.81, "10th_percentile": 31.81, "90th_percentile": 31.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 31.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 31.81, "10th_percentile": 31.81, "90th_percentile": 31.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 31.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 31.81, "10th_percentile": 31.81, "90th_percentile": 31.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 31.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 31.81, "10th_percentile": 31.81, "90th_percentile": 31.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 31.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 31.81, "10th_percentile": 31.81, "90th_percentile": 31.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 31.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 31.81, "10th_percentile": 31.81, "90th_percentile": 31.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 31.81, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 31.81, "10th_percentile": 31.81, "90th_percentile": 31.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "CANNULA PRFSN 15FR 11IN MLTPRT TP PVC WR WND BDY AUTO INFLT", "code_information": [ { "code": "SUP-435646", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 25.22, "maximum": 180.3, "setting": "outpatient", "gross_charge": 180.3, "discounted_cash": 126.21, "payers_information": [ { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 135.23, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 135.23, "10th_percentile": 135.23, "90th_percentile": 135.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 135.23, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 135.23, "10th_percentile": 135.23, "90th_percentile": 135.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 153.26, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 153.26, "10th_percentile": 153.26, "90th_percentile": 153.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 126.21, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 126.21, "10th_percentile": 126.21, "90th_percentile": 126.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 90.15, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 90.15, "10th_percentile": 90.15, "90th_percentile": 90.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 108.18, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 108.18, "10th_percentile": 108.18, "90th_percentile": 108.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 115.81, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 115.81, "10th_percentile": 115.81, "90th_percentile": 115.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 180.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 180.3, "10th_percentile": 180.3, "90th_percentile": 180.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 81.68, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 81.68, "10th_percentile": 81.68, "90th_percentile": 81.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 92.13, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 92.13, "10th_percentile": 92.13, "90th_percentile": 92.13, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 102.41, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 102.41, "10th_percentile": 102.41, "90th_percentile": 102.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 180.3, "10th_percentile": 180.3, "90th_percentile": 180.3, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 180.3, "10th_percentile": 180.3, "90th_percentile": 180.3, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 180.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 180.3, "10th_percentile": 180.3, "90th_percentile": 180.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 180.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 180.3, "10th_percentile": 180.3, "90th_percentile": 180.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 180.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 180.3, "10th_percentile": 180.3, "90th_percentile": 180.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 180.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 180.3, "10th_percentile": 180.3, "90th_percentile": 180.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 180.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 180.3, "10th_percentile": 180.3, "90th_percentile": 180.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 180.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 180.3, "10th_percentile": 180.3, "90th_percentile": 180.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 180.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 180.3, "10th_percentile": 180.3, "90th_percentile": 180.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 70.55, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 70.55, "10th_percentile": 70.55, "90th_percentile": 70.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 70.55, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 70.55, "10th_percentile": 70.55, "90th_percentile": 70.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 79.84, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 79.84, "10th_percentile": 79.84, "90th_percentile": 79.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 79.84, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 79.84, "10th_percentile": 79.84, "90th_percentile": 79.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 102.41, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 102.41, "10th_percentile": 102.41, "90th_percentile": 102.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 38.76, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 38.76, "10th_percentile": 38.76, "90th_percentile": 38.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 61.12, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 61.12, "10th_percentile": 61.12, "90th_percentile": 61.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 90.15, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 90.15, "10th_percentile": 90.15, "90th_percentile": 90.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 144.24, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 144.24, "10th_percentile": 144.24, "90th_percentile": 144.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 33.72, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33.72, "10th_percentile": 33.72, "90th_percentile": 33.72, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 144.24, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 144.24, "10th_percentile": 144.24, "90th_percentile": 144.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 53.37, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 53.37, "10th_percentile": 53.37, "90th_percentile": 53.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 180.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $180.30 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 180.3, "10th_percentile": 180.3, "90th_percentile": 180.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $180.30 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 30.52, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 30.52, "10th_percentile": 30.52, "90th_percentile": 30.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 25.22, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.22, "10th_percentile": 25.22, "90th_percentile": 25.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 25.73, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.73, "10th_percentile": 25.73, "90th_percentile": 25.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 180.3, "10th_percentile": 180.3, "90th_percentile": 180.3, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 180.3, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 180.3, "10th_percentile": 180.3, "90th_percentile": 180.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "CANNULA THREADED 8.25X7CM AR-6530", "code_information": [ { "code": "SUP-9054341", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 9.21, "maximum": 65.86, "setting": "outpatient", "gross_charge": 65.86, "discounted_cash": 46.1, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 11.15, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.15, "10th_percentile": 11.15, "90th_percentile": 11.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 29.16, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 29.16, "10th_percentile": 29.16, "90th_percentile": 29.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 25.77, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.77, "10th_percentile": 25.77, "90th_percentile": 25.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 9.4, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.4, "10th_percentile": 9.4, "90th_percentile": 9.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 9.21, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 9.21, "10th_percentile": 9.21, "90th_percentile": 9.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 65.86, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $65.86 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 65.86, "10th_percentile": 65.86, "90th_percentile": 65.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $65.86 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 55.98, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 55.98, "10th_percentile": 55.98, "90th_percentile": 55.98, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 42.3, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 42.3, "10th_percentile": 42.3, "90th_percentile": 42.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 32.93, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 32.93, "10th_percentile": 32.93, "90th_percentile": 32.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 22.33, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 22.33, "10th_percentile": 22.33, "90th_percentile": 22.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 46.1, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 46.1, "10th_percentile": 46.1, "90th_percentile": 46.1, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 49.4, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 49.4, "10th_percentile": 49.4, "90th_percentile": 49.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 29.16, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 29.16, "10th_percentile": 29.16, "90th_percentile": 29.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 32.93, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 32.93, "10th_percentile": 32.93, "90th_percentile": 32.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 52.69, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 52.69, "10th_percentile": 52.69, "90th_percentile": 52.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 39.52, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 39.52, "10th_percentile": 39.52, "90th_percentile": 39.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 14.16, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 14.16, "10th_percentile": 14.16, "90th_percentile": 14.16, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 25.77, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 25.77, "10th_percentile": 25.77, "90th_percentile": 25.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 49.4, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 49.4, "10th_percentile": 49.4, "90th_percentile": 49.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 19.49, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 19.49, "10th_percentile": 19.49, "90th_percentile": 19.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 12.32, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 12.32, "10th_percentile": 12.32, "90th_percentile": 12.32, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 52.69, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 52.69, "10th_percentile": 52.69, "90th_percentile": 52.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 65.86, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 65.86, "10th_percentile": 65.86, "90th_percentile": 65.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 29.83, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 29.83, "10th_percentile": 29.83, "90th_percentile": 29.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 33.65, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 33.65, "10th_percentile": 33.65, "90th_percentile": 33.65, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 37.41, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 37.41, "10th_percentile": 37.41, "90th_percentile": 37.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 37.41, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 37.41, "10th_percentile": 37.41, "90th_percentile": 37.41, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 65.86, "10th_percentile": 65.86, "90th_percentile": 65.86, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 65.86, "10th_percentile": 65.86, "90th_percentile": 65.86, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 65.86, "10th_percentile": 65.86, "90th_percentile": 65.86, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 65.86, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 65.86, "10th_percentile": 65.86, "90th_percentile": 65.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 65.86, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 65.86, "10th_percentile": 65.86, "90th_percentile": 65.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 65.86, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 65.86, "10th_percentile": 65.86, "90th_percentile": 65.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 65.86, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 65.86, "10th_percentile": 65.86, "90th_percentile": 65.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 65.86, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 65.86, "10th_percentile": 65.86, "90th_percentile": 65.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 65.86, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 65.86, "10th_percentile": 65.86, "90th_percentile": 65.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 65.86, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 65.86, "10th_percentile": 65.86, "90th_percentile": 65.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 65.86, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 65.86, "10th_percentile": 65.86, "90th_percentile": 65.86, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "CANNULA THREADED CLEAR 5.5X75MM 214108", "code_information": [ { "code": "SUP-335589", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 11.06, "maximum": 79.04, "setting": "outpatient", "gross_charge": 79.04, "discounted_cash": 55.33, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 13.38, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 13.38, "10th_percentile": 13.38, "90th_percentile": 13.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 35.0, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 35.0, "10th_percentile": 35.0, "90th_percentile": 35.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 30.93, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 30.93, "10th_percentile": 30.93, "90th_percentile": 30.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 11.28, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.28, "10th_percentile": 11.28, "90th_percentile": 11.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 11.06, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 11.06, "10th_percentile": 11.06, "90th_percentile": 11.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 79.04, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $79.04 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 79.04, "10th_percentile": 79.04, "90th_percentile": 79.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $79.04 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 67.18, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 67.18, "10th_percentile": 67.18, "90th_percentile": 67.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 50.77, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 50.77, "10th_percentile": 50.77, "90th_percentile": 50.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 39.52, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 39.52, "10th_percentile": 39.52, "90th_percentile": 39.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 26.79, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 26.79, "10th_percentile": 26.79, "90th_percentile": 26.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 55.33, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 55.33, "10th_percentile": 55.33, "90th_percentile": 55.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 59.28, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 59.28, "10th_percentile": 59.28, "90th_percentile": 59.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 35.0, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 35.0, "10th_percentile": 35.0, "90th_percentile": 35.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 39.52, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 39.52, "10th_percentile": 39.52, "90th_percentile": 39.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 63.23, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 63.23, "10th_percentile": 63.23, "90th_percentile": 63.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 47.42, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 47.42, "10th_percentile": 47.42, "90th_percentile": 47.42, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 16.99, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 16.99, "10th_percentile": 16.99, "90th_percentile": 16.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 30.93, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 30.93, "10th_percentile": 30.93, "90th_percentile": 30.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 59.28, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 59.28, "10th_percentile": 59.28, "90th_percentile": 59.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 23.4, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 23.4, "10th_percentile": 23.4, "90th_percentile": 23.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 14.78, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 14.78, "10th_percentile": 14.78, "90th_percentile": 14.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 63.23, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 63.23, "10th_percentile": 63.23, "90th_percentile": 63.23, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 79.04, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 79.04, "10th_percentile": 79.04, "90th_percentile": 79.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 35.81, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 35.81, "10th_percentile": 35.81, "90th_percentile": 35.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 40.39, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 40.39, "10th_percentile": 40.39, "90th_percentile": 40.39, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 44.89, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 44.89, "10th_percentile": 44.89, "90th_percentile": 44.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 44.89, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 44.89, "10th_percentile": 44.89, "90th_percentile": 44.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 79.04, "10th_percentile": 79.04, "90th_percentile": 79.04, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 79.04, "10th_percentile": 79.04, "90th_percentile": 79.04, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 79.04, "10th_percentile": 79.04, "90th_percentile": 79.04, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 79.04, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 79.04, "10th_percentile": 79.04, "90th_percentile": 79.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 79.04, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 79.04, "10th_percentile": 79.04, "90th_percentile": 79.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 79.04, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 79.04, "10th_percentile": 79.04, "90th_percentile": 79.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 79.04, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 79.04, "10th_percentile": 79.04, "90th_percentile": 79.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 79.04, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 79.04, "10th_percentile": 79.04, "90th_percentile": 79.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 79.04, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 79.04, "10th_percentile": 79.04, "90th_percentile": 79.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 79.04, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 79.04, "10th_percentile": 79.04, "90th_percentile": 79.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 79.04, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 79.04, "10th_percentile": 79.04, "90th_percentile": 79.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "CAP CNNL 8MM STNDRD LNGTH OBTRTR WTH BLDLSS ARSL", "code_information": [ { "code": "SUP-432183", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 35.17, "maximum": 251.36, "setting": "outpatient", "gross_charge": 251.36, "discounted_cash": 175.95, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 98.36, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 98.36, "10th_percentile": 98.36, "90th_percentile": 98.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 42.56, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 42.56, "10th_percentile": 42.56, "90th_percentile": 42.56, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 35.87, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 35.87, "10th_percentile": 35.87, "90th_percentile": 35.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 35.17, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 35.17, "10th_percentile": 35.17, "90th_percentile": 35.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 111.3, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 111.3, "10th_percentile": 111.3, "90th_percentile": 111.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 251.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $251.36 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 251.36, "10th_percentile": 251.36, "90th_percentile": 251.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $251.36 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 85.21, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 85.21, "10th_percentile": 85.21, "90th_percentile": 85.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 54.04, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 54.04, "10th_percentile": 54.04, "90th_percentile": 54.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 98.36, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 98.36, "10th_percentile": 98.36, "90th_percentile": 98.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 125.68, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 125.68, "10th_percentile": 125.68, "90th_percentile": 125.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 111.3, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 111.3, "10th_percentile": 111.3, "90th_percentile": 111.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 201.09, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 201.09, "10th_percentile": 201.09, "90th_percentile": 201.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 47.0, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 47.0, "10th_percentile": 47.0, "90th_percentile": 47.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 74.4, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 74.4, "10th_percentile": 74.4, "90th_percentile": 74.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 201.09, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 201.09, "10th_percentile": 201.09, "90th_percentile": 201.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 142.77, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 142.77, "10th_percentile": 142.77, "90th_percentile": 142.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 251.36, "10th_percentile": 251.36, "90th_percentile": 251.36, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 251.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 251.36, "10th_percentile": 251.36, "90th_percentile": 251.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 251.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 251.36, "10th_percentile": 251.36, "90th_percentile": 251.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 213.66, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 213.66, "10th_percentile": 213.66, "90th_percentile": 213.66, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 161.45, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 161.45, "10th_percentile": 161.45, "90th_percentile": 161.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 125.68, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 125.68, "10th_percentile": 125.68, "90th_percentile": 125.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 175.95, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 175.95, "10th_percentile": 175.95, "90th_percentile": 175.95, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 188.52, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 188.52, "10th_percentile": 188.52, "90th_percentile": 188.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 150.82, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 150.82, "10th_percentile": 150.82, "90th_percentile": 150.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 188.52, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 188.52, "10th_percentile": 188.52, "90th_percentile": 188.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 251.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 251.36, "10th_percentile": 251.36, "90th_percentile": 251.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 113.87, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 113.87, "10th_percentile": 113.87, "90th_percentile": 113.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 128.44, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 128.44, "10th_percentile": 128.44, "90th_percentile": 128.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 142.77, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 142.77, "10th_percentile": 142.77, "90th_percentile": 142.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 251.36, "10th_percentile": 251.36, "90th_percentile": 251.36, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 251.36, "10th_percentile": 251.36, "90th_percentile": 251.36, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 251.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 251.36, "10th_percentile": 251.36, "90th_percentile": 251.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 251.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 251.36, "10th_percentile": 251.36, "90th_percentile": 251.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 251.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 251.36, "10th_percentile": 251.36, "90th_percentile": 251.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 251.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 251.36, "10th_percentile": 251.36, "90th_percentile": 251.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 251.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 251.36, "10th_percentile": 251.36, "90th_percentile": 251.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 251.36, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 251.36, "10th_percentile": 251.36, "90th_percentile": 251.36, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "CAP PIN BLUE 0.035IN", "code_information": [ { "code": "SUP-9020077", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 0.33, "maximum": 2.34, "setting": "outpatient", "gross_charge": 2.34, "discounted_cash": 1.64, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.92, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.92, "10th_percentile": 0.92, "90th_percentile": 0.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.92, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.92, "10th_percentile": 0.92, "90th_percentile": 0.92, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1.04, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.04, "10th_percentile": 1.04, "90th_percentile": 1.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 1.04, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.04, "10th_percentile": 1.04, "90th_percentile": 1.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.33, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.33, "10th_percentile": 1.33, "90th_percentile": 1.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.33, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.33, "10th_percentile": 1.33, "90th_percentile": 1.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1.76, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1.76, "10th_percentile": 1.76, "90th_percentile": 1.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.5, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.5, "10th_percentile": 0.5, "90th_percentile": 0.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.79, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.79, "10th_percentile": 0.79, "90th_percentile": 0.79, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1.76, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1.76, "10th_percentile": 1.76, "90th_percentile": 1.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.17, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.17, "10th_percentile": 1.17, "90th_percentile": 1.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1.87, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1.87, "10th_percentile": 1.87, "90th_percentile": 1.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.44, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.44, "10th_percentile": 0.44, "90th_percentile": 0.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1.87, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.87, "10th_percentile": 1.87, "90th_percentile": 1.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 0.69, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.69, "10th_percentile": 0.69, "90th_percentile": 0.69, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.34, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.34 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.34, "10th_percentile": 2.34, "90th_percentile": 2.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.34 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.4, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.4, "10th_percentile": 0.4, "90th_percentile": 0.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.33, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.33, "10th_percentile": 0.33, "90th_percentile": 0.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.33, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.33, "10th_percentile": 0.33, "90th_percentile": 0.33, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.34, "10th_percentile": 2.34, "90th_percentile": 2.34, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.34, "10th_percentile": 2.34, "90th_percentile": 2.34, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.34, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.34, "10th_percentile": 2.34, "90th_percentile": 2.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.34, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.34, "10th_percentile": 2.34, "90th_percentile": 2.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.34, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.34, "10th_percentile": 2.34, "90th_percentile": 2.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1.99, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1.99, "10th_percentile": 1.99, "90th_percentile": 1.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1.5, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.17, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.17, "10th_percentile": 1.17, "90th_percentile": 1.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1.64, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1.64, "10th_percentile": 1.64, "90th_percentile": 1.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1.4, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1.4, "10th_percentile": 1.4, "90th_percentile": 1.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.34, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.34, "10th_percentile": 2.34, "90th_percentile": 2.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 1.06, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.06, "10th_percentile": 1.06, "90th_percentile": 1.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1.2, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.2, "10th_percentile": 1.2, "90th_percentile": 1.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.34, "10th_percentile": 2.34, "90th_percentile": 2.34, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.34, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.34, "10th_percentile": 2.34, "90th_percentile": 2.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.34, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.34, "10th_percentile": 2.34, "90th_percentile": 2.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.34, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.34, "10th_percentile": 2.34, "90th_percentile": 2.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.34, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.34, "10th_percentile": 2.34, "90th_percentile": 2.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.34, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.34, "10th_percentile": 2.34, "90th_percentile": 2.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "CAP PROTCT WRE EXT FIX 2.5MM BLU", "code_information": [ { "code": "SUP-369703", "type": "CDM" }, { "code": "27200001", "type": "LOCAL" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "minimum": 0.87, "maximum": 6.24, "setting": "outpatient", "gross_charge": 6.24, "discounted_cash": 4.37, "payers_information": [ { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2.44, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.44, "10th_percentile": 2.44, "90th_percentile": 2.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.06, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.06, "10th_percentile": 1.06, "90th_percentile": 1.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.89, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.89, "10th_percentile": 0.89, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.87, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.87, "10th_percentile": 0.87, "90th_percentile": 0.87, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 2.76, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.76, "10th_percentile": 2.76, "90th_percentile": 2.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 6.24, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6.24 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 6.24, "10th_percentile": 6.24, "90th_percentile": 6.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6.24 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 2.12, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 2.12, "10th_percentile": 2.12, "90th_percentile": 2.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 1.34, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 1.34, "10th_percentile": 1.34, "90th_percentile": 1.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 4.68, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 4.68, "10th_percentile": 4.68, "90th_percentile": 4.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 4.68, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 4.68, "10th_percentile": 4.68, "90th_percentile": 4.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2.44, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.44, "10th_percentile": 2.44, "90th_percentile": 2.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 5.3, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 5.3, "10th_percentile": 5.3, "90th_percentile": 5.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 4.37, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 4.37, "10th_percentile": 4.37, "90th_percentile": 4.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 3.12, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 3.12, "10th_percentile": 3.12, "90th_percentile": 3.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 3.12, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.12, "10th_percentile": 3.12, "90th_percentile": 3.12, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 3.74, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 3.74, "10th_percentile": 3.74, "90th_percentile": 3.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 4.01, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 4.01, "10th_percentile": 4.01, "90th_percentile": 4.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 2.76, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.76, "10th_percentile": 2.76, "90th_percentile": 2.76, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 4.99, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 4.99, "10th_percentile": 4.99, "90th_percentile": 4.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 1.17, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.17, "10th_percentile": 1.17, "90th_percentile": 1.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 1.85, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.85, "10th_percentile": 1.85, "90th_percentile": 1.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 4.99, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 4.99, "10th_percentile": 4.99, "90th_percentile": 4.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 6.24, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 6.24, "10th_percentile": 6.24, "90th_percentile": 6.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 2.83, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.83, "10th_percentile": 2.83, "90th_percentile": 2.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 3.19, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.19, "10th_percentile": 3.19, "90th_percentile": 3.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 3.54, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.54, "10th_percentile": 3.54, "90th_percentile": 3.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 3.54, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.54, "10th_percentile": 3.54, "90th_percentile": 3.54, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 6.24, "10th_percentile": 6.24, "90th_percentile": 6.24, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6.24, "10th_percentile": 6.24, "90th_percentile": 6.24, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6.24, "10th_percentile": 6.24, "90th_percentile": 6.24, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.24, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.24, "10th_percentile": 6.24, "90th_percentile": 6.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.24, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.24, "10th_percentile": 6.24, "90th_percentile": 6.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.24, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.24, "10th_percentile": 6.24, "90th_percentile": 6.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.24, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.24, "10th_percentile": 6.24, "90th_percentile": 6.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.24, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.24, "10th_percentile": 6.24, "90th_percentile": 6.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.24, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.24, "10th_percentile": 6.24, "90th_percentile": 6.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.24, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.24, "10th_percentile": 6.24, "90th_percentile": 6.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.24, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.24, "10th_percentile": 6.24, "90th_percentile": 6.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "CARBAMAZEPINE 100 MG/5 ML ORAL SUSP", "drug_information": { "unit": 10.0, "type": "ML" }, "code_information": [ { "code": "RX-1356", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "99991-0034-34", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.94, "maximum": 6.75, "setting": "outpatient", "gross_charge": 6.75, "discounted_cash": 4.72, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.75, "10th_percentile": 6.75, "90th_percentile": 6.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.75, "10th_percentile": 6.75, "90th_percentile": 6.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.75, "10th_percentile": 6.75, "90th_percentile": 6.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.75, "10th_percentile": 6.75, "90th_percentile": 6.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.75, "10th_percentile": 6.75, "90th_percentile": 6.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.75, "10th_percentile": 6.75, "90th_percentile": 6.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.75, "10th_percentile": 6.75, "90th_percentile": 6.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 6.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 6.75, "10th_percentile": 6.75, "90th_percentile": 6.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 3.83, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.83, "10th_percentile": 3.83, "90th_percentile": 3.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 3.83, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.83, "10th_percentile": 3.83, "90th_percentile": 3.83, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 2.29, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 2.29, "10th_percentile": 2.29, "90th_percentile": 2.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 1.45, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 1.45, "10th_percentile": 1.45, "90th_percentile": 1.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2.64, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.64, "10th_percentile": 2.64, "90th_percentile": 2.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 2.99, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.99, "10th_percentile": 2.99, "90th_percentile": 2.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 5.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 5.4, "10th_percentile": 5.4, "90th_percentile": 5.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 3.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.38, "10th_percentile": 3.38, "90th_percentile": 3.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 1.26, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.26, "10th_percentile": 1.26, "90th_percentile": 1.26, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 5.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 5.4, "10th_percentile": 5.4, "90th_percentile": 5.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 2.0, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 5.06, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 5.06, "10th_percentile": 5.06, "90th_percentile": 5.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 5.06, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 5.06, "10th_percentile": 5.06, "90th_percentile": 5.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 5.74, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 5.74, "10th_percentile": 5.74, "90th_percentile": 5.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 3.38, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 3.38, "10th_percentile": 3.38, "90th_percentile": 3.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 4.05, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 4.05, "10th_percentile": 4.05, "90th_percentile": 4.05, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 4.73, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 4.73, "10th_percentile": 4.73, "90th_percentile": 4.73, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 4.34, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 4.34, "10th_percentile": 4.34, "90th_percentile": 4.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 3.45, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.45, "10th_percentile": 3.45, "90th_percentile": 3.45, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 3.06, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 3.06, "10th_percentile": 3.06, "90th_percentile": 3.06, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 6.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 6.75, "10th_percentile": 6.75, "90th_percentile": 6.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 6.75, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 6.75, "10th_percentile": 6.75, "90th_percentile": 6.75, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $6.75 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.96, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.96, "10th_percentile": 0.96, "90th_percentile": 0.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 2.64, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.64, "10th_percentile": 2.64, "90th_percentile": 2.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 1.14, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 2.99, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 2.99, "10th_percentile": 2.99, "90th_percentile": 2.99, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.94, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.94, "10th_percentile": 0.94, "90th_percentile": 0.94, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6.75, "10th_percentile": 6.75, "90th_percentile": 6.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 6.75, "10th_percentile": 6.75, "90th_percentile": 6.75, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 6.75, "10th_percentile": 6.75, "90th_percentile": 6.75, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" } ] } ] }, { "description": "CARBIDOPA-LEVODOPA 10-100 MG ORAL TAB", "drug_information": { "unit": 1.0, "type": "UN" }, "code_information": [ { "code": "RX-9406", "type": "CDM" }, { "code": "63700000", "type": "LOCAL" }, { "code": "0637", "type": "RC" }, { "code": "00093-9701-01", "type": "NDC" } ], "standard_charges": [ { "minimum": 0.28, "maximum": 2.0, "setting": "outpatient", "gross_charge": 2.0, "discounted_cash": 1.4, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $2.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 2.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 0.78, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.78, "10th_percentile": 0.78, "90th_percentile": 0.78, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1.6, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1.6, "10th_percentile": 1.6, "90th_percentile": 1.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.89, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.89, "10th_percentile": 0.89, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 0.89, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.89, "10th_percentile": 0.89, "90th_percentile": 0.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 1.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.0, "10th_percentile": 1.0, "90th_percentile": 1.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1.5, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1.5, "10th_percentile": 1.5, "90th_percentile": 1.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1.14, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.14, "10th_percentile": 1.14, "90th_percentile": 1.14, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 0.68, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 0.68, "10th_percentile": 0.68, "90th_percentile": 0.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 0.28, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.28, "10th_percentile": 0.28, "90th_percentile": 0.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 0.43, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 0.43, "10th_percentile": 0.43, "90th_percentile": 0.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 0.34, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.34, "10th_percentile": 0.34, "90th_percentile": 0.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 0.37, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.37, "10th_percentile": 0.37, "90th_percentile": 0.37, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 0.29, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.29, "10th_percentile": 0.29, "90th_percentile": 0.29, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1.7, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1.7, "10th_percentile": 1.7, "90th_percentile": 1.7, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1.28, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1.28, "10th_percentile": 1.28, "90th_percentile": 1.28, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1.02, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1.02, "10th_percentile": 1.02, "90th_percentile": 1.02, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 0.59, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.59, "10th_percentile": 0.59, "90th_percentile": 0.59, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 0.91, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 0.91, "10th_percentile": 0.91, "90th_percentile": 0.91, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1.2, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1.2, "10th_percentile": 1.2, "90th_percentile": 1.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1.4, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1.4, "10th_percentile": 1.4, "90th_percentile": 1.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" } ] } ] }, { "description": "CARBOPLATIN 10 MG/ML IV SOLN", "drug_information": { "unit": 45.0, "type": "ML" }, "code_information": [ { "code": "RX-39267", "type": "CDM" }, { "code": "J9045", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "00703-4248-81", "type": "NDC" } ], "standard_charges": [ { "minimum": 56.84, "maximum": 355.25, "setting": "outpatient", "gross_charge": 355.25, "discounted_cash": 248.67, "payers_information": [ { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 355.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 355.25, "10th_percentile": 355.25, "90th_percentile": 355.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 355.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 355.25, "10th_percentile": 355.25, "90th_percentile": 355.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 355.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 355.25, "10th_percentile": 355.25, "90th_percentile": 355.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 355.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 355.25, "10th_percentile": 355.25, "90th_percentile": 355.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 355.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 355.25, "10th_percentile": 355.25, "90th_percentile": 355.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 355.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 355.25, "10th_percentile": 355.25, "90th_percentile": 355.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 355.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 355.25, "10th_percentile": 355.25, "90th_percentile": 355.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 355.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 355.25, "10th_percentile": 355.25, "90th_percentile": 355.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 355.25, "10th_percentile": 355.25, "90th_percentile": 355.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 355.25, "10th_percentile": 355.25, "90th_percentile": 355.25, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 355.25, "10th_percentile": 355.25, "90th_percentile": 355.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_algorithm": "No contract line matched", "median_amount": 355.25, "10th_percentile": 355.25, "90th_percentile": 355.25, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 56.84, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 56.84, "10th_percentile": 56.84, "90th_percentile": 56.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 56.84, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 56.84, "10th_percentile": 56.84, "90th_percentile": 56.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 56.84, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 56.84, "10th_percentile": 56.84, "90th_percentile": 56.84, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 139.01, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 139.01, "10th_percentile": 139.01, "90th_percentile": 139.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 139.01, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 139.01, "10th_percentile": 139.01, "90th_percentile": 139.01, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 68.21, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 68.21, "10th_percentile": 68.21, "90th_percentile": 68.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 68.21, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 68.21, "10th_percentile": 68.21, "90th_percentile": 68.21, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 355.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $355.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 355.25, "10th_percentile": 355.25, "90th_percentile": 355.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $355.25 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 284.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 284.2, "10th_percentile": 284.2, "90th_percentile": 284.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 76.38, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 76.38, "10th_percentile": 76.38, "90th_percentile": 76.38, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 120.43, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 120.43, "10th_percentile": 120.43, "90th_percentile": 120.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 177.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 177.63, "10th_percentile": 177.63, "90th_percentile": 177.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 284.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 284.2, "10th_percentile": 284.2, "90th_percentile": 284.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 213.15, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 213.15, "10th_percentile": 213.15, "90th_percentile": 213.15, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 266.44, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 266.44, "10th_percentile": 266.44, "90th_percentile": 266.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 355.25, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 355.25, "10th_percentile": 355.25, "90th_percentile": 355.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 301.96, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 301.96, "10th_percentile": 301.96, "90th_percentile": 301.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 248.68, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 248.68, "10th_percentile": 248.68, "90th_percentile": 248.68, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 177.63, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 177.63, "10th_percentile": 177.63, "90th_percentile": 177.63, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 266.44, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 266.44, "10th_percentile": 266.44, "90th_percentile": 266.44, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" } ] } ] }, { "description": "CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN", "drug_information": { "unit": 1.0, "type": "ML" }, "code_information": [ { "code": "RX-9413", "type": "CDM" }, { "code": "J0675", "type": "HCPCS" }, { "code": "0636", "type": "RC" }, { "code": "43598-0917-11", "type": "NDC" } ], "standard_charges": [ { "minimum": 279.04, "maximum": 1744.0, "setting": "outpatient", "gross_charge": 1744.0, "discounted_cash": 1220.8, "payers_information": [ { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1744.0, "10th_percentile": 1744.0, "90th_percentile": 1744.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1744.0, "10th_percentile": 1744.0, "90th_percentile": 1744.0, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1744.0, "10th_percentile": 1744.0, "90th_percentile": 1744.0, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 334.85, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 334.85, "10th_percentile": 334.85, "90th_percentile": 334.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 334.85, "standard_charge_percentage": 19.2, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 334.85, "10th_percentile": 334.85, "90th_percentile": 334.85, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 19.2% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1308.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1308.0, "10th_percentile": 1308.0, "90th_percentile": 1308.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 872.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 872.0, "10th_percentile": 872.0, "90th_percentile": 872.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1395.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1395.2, "10th_percentile": 1395.2, "90th_percentile": 1395.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1744.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1744.0, "10th_percentile": 1744.0, "90th_percentile": 1744.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1046.4, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1046.4, "10th_percentile": 1046.4, "90th_percentile": 1046.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1220.8, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1220.8, "10th_percentile": 1220.8, "90th_percentile": 1220.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 591.22, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 591.22, "10th_percentile": 591.22, "90th_percentile": 591.22, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1308.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1308.0, "10th_percentile": 1308.0, "90th_percentile": 1308.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1395.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1395.2, "10th_percentile": 1395.2, "90th_percentile": 1395.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1482.4, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1482.4, "10th_percentile": 1482.4, "90th_percentile": 1482.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 872.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 872.0, "10th_percentile": 872.0, "90th_percentile": 872.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 374.96, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 374.96, "10th_percentile": 374.96, "90th_percentile": 374.96, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1744.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,744.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1744.0, "10th_percentile": 1744.0, "90th_percentile": 1744.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,744.00 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 891.18, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 891.18, "10th_percentile": 891.18, "90th_percentile": 891.18, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 790.03, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 790.03, "10th_percentile": 790.03, "90th_percentile": 790.03, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1120.17, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1120.17, "10th_percentile": 1120.17, "90th_percentile": 1120.17, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 682.43, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 682.43, "10th_percentile": 682.43, "90th_percentile": 682.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 682.43, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 682.43, "10th_percentile": 682.43, "90th_percentile": 682.43, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 279.04, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 279.04, "10th_percentile": 279.04, "90th_percentile": 279.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 279.04, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 279.04, "10th_percentile": 279.04, "90th_percentile": 279.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 279.04, "standard_charge_percentage": 16.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 279.04, "10th_percentile": 279.04, "90th_percentile": 279.04, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 16% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1744.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1744.0, "10th_percentile": 1744.0, "90th_percentile": 1744.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1744.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1744.0, "10th_percentile": 1744.0, "90th_percentile": 1744.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1744.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1744.0, "10th_percentile": 1744.0, "90th_percentile": 1744.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1744.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1744.0, "10th_percentile": 1744.0, "90th_percentile": 1744.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1744.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1744.0, "10th_percentile": 1744.0, "90th_percentile": 1744.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1744.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1744.0, "10th_percentile": 1744.0, "90th_percentile": 1744.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1744.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1744.0, "10th_percentile": 1744.0, "90th_percentile": 1744.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1744.0, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1744.0, "10th_percentile": 1744.0, "90th_percentile": 1744.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "CARDIOPLEGIA SOLUTION REPERFUSATE NO POTASSIUM", "drug_information": { "unit": 238.75, "type": "ML" }, "code_information": [ { "code": "RX-4080000267", "type": "CDM" }, { "code": "27200000", "type": "LOCAL" }, { "code": "0272", "type": "RC" }, { "code": "66647-0120-05", "type": "NDC" } ], "standard_charges": [ { "minimum": 275.11, "maximum": 1966.5, "setting": "outpatient", "gross_charge": 1966.5, "discounted_cash": 1376.55, "payers_information": [ { "payer_name": "ALTERNATE BLUE CROSS MEDICARE ADV [2304]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1966.5, "10th_percentile": 1966.5, "90th_percentile": 1966.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH MEDICARE", "standard_charge_algorithm": "APC grouping requires price history; No contract line matched", "median_amount": 1966.5, "10th_percentile": 1966.5, "90th_percentile": 1966.5, "count": "0", "methodology": "other", "additional_payer_notes": "APC grouping requires price history; No contract line matched" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1966.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1966.5, "10th_percentile": 1966.5, "90th_percentile": 1966.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1966.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1966.5, "10th_percentile": 1966.5, "90th_percentile": 1966.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "GALAXY HEALTH NETWORK [220]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1966.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1966.5, "10th_percentile": 1966.5, "90th_percentile": 1966.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 1116.97, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1116.97, "10th_percentile": 1116.97, "90th_percentile": 1116.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 666.64, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 666.64, "10th_percentile": 666.64, "90th_percentile": 666.64, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 422.8, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 422.8, "10th_percentile": 422.8, "90th_percentile": 422.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 769.49, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 769.49, "10th_percentile": 769.49, "90th_percentile": 769.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 870.77, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 870.77, "10th_percentile": 870.77, "90th_percentile": 870.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 1573.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 1573.2, "10th_percentile": 1573.2, "90th_percentile": 1573.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 332.93, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 332.93, "10th_percentile": 332.93, "90th_percentile": 332.93, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 275.11, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 275.11, "10th_percentile": 275.11, "90th_percentile": 275.11, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 280.62, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 280.62, "10th_percentile": 280.62, "90th_percentile": 280.62, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 769.49, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 769.49, "10th_percentile": 769.49, "90th_percentile": 769.49, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PAR/INDEMNITY ADP", "standard_charge_dollar": 1966.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,966.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount.", "median_amount": 1966.5, "10th_percentile": 1966.5, "90th_percentile": 1966.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP. ADP RATE (for patient estimates only); 100% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid $1,966.50 so that total pmt for all claim lines does not exceed 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 870.77, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 870.77, "10th_percentile": 870.77, "90th_percentile": 870.77, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 983.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 983.25, "10th_percentile": 983.25, "90th_percentile": 983.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 367.74, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 367.74, "10th_percentile": 367.74, "90th_percentile": 367.74, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 1573.2, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1573.2, "10th_percentile": 1573.2, "90th_percentile": 1573.2, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 582.08, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 582.08, "10th_percentile": 582.08, "90th_percentile": 582.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 1474.88, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 1474.88, "10th_percentile": 1474.88, "90th_percentile": 1474.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 1116.97, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1116.97, "10th_percentile": 1116.97, "90th_percentile": 1116.97, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 1474.88, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 1474.88, "10th_percentile": 1474.88, "90th_percentile": 1474.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 1671.53, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 1671.53, "10th_percentile": 1671.53, "90th_percentile": 1671.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 983.25, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 983.25, "10th_percentile": 983.25, "90th_percentile": 983.25, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 1179.9, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 1179.9, "10th_percentile": 1179.9, "90th_percentile": 1179.9, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 1376.55, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 1376.55, "10th_percentile": 1376.55, "90th_percentile": 1376.55, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 1263.08, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 1263.08, "10th_percentile": 1263.08, "90th_percentile": 1263.08, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 1004.88, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 1004.88, "10th_percentile": 1004.88, "90th_percentile": 1004.88, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC CORE", "standard_charge_dollar": 890.82, "standard_charge_percentage": 45.3, "standard_charge_algorithm": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 890.82, "10th_percentile": 890.82, "90th_percentile": 890.82, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Table 5 Services; 45.3% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC NON-CONTRACTED OON - ED ONLY", "standard_charge_dollar": 1966.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services - OON; 100% Billed", "median_amount": 1966.5, "10th_percentile": 1966.5, "90th_percentile": 1966.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services - OON; 100% Billed" }, { "payer_name": "OPTUM/UNITED BEHAVIORAL HEALTH [157]", "plan_name": "PH UBH BHS", "standard_charge_algorithm": "No contract line matched", "median_amount": 1966.5, "10th_percentile": 1966.5, "90th_percentile": 1966.5, "count": "0", "methodology": "other", "additional_payer_notes": "No contract line matched" }, { "payer_name": "GLOBAL EXCEL [1712]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1966.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1966.5, "10th_percentile": 1966.5, "90th_percentile": 1966.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTH ALLIANCE [181]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1966.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1966.5, "10th_percentile": 1966.5, "90th_percentile": 1966.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1966.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1966.5, "10th_percentile": 1966.5, "90th_percentile": 1966.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1966.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1966.5, "10th_percentile": 1966.5, "90th_percentile": 1966.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH NON-CONTRACTED PAYORS", "standard_charge_dollar": 1966.5, "standard_charge_percentage": 100.0, "standard_charge_algorithm": "All OP Services; 100% Billed", "median_amount": 1966.5, "10th_percentile": 1966.5, "90th_percentile": 1966.5, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All OP Services; 100% Billed" } ] } ] }, { "description": "CARDIOPLEGIC SOLN 16 MEQ/L (= K+) PERF SOLN", "drug_information": { "unit": 1000.0, "type": "ML" }, "code_information": [ { "code": "RX-30275", "type": "CDM" }, { "code": "27200000", "type": "LOCAL" }, { "code": "0272", "type": "RC" }, { "code": "00409-7969-05", "type": "NDC" } ], "standard_charges": [ { "minimum": 45.89, "maximum": 328.0, "setting": "outpatient", "gross_charge": 328.0, "discounted_cash": 229.6, "payers_information": [ { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA", "standard_charge_dollar": 186.3, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 186.3, "10th_percentile": 186.3, "90th_percentile": 186.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA IL PREFERRED", "standard_charge_dollar": 111.19, "standard_charge_percentage": 33.9, "standard_charge_algorithm": "All Outpatient Services; 33.9% Billed", "median_amount": 111.19, "10th_percentile": 111.19, "90th_percentile": 111.19, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Outpatient Services; 33.9% Billed" }, { "payer_name": "AETNA HEALTH PLAN [171]", "plan_name": "PH AETNA NM EMPLOYEES", "standard_charge_dollar": 70.52, "standard_charge_percentage": 21.5, "standard_charge_algorithm": "All Services; 21.5% Billed", "median_amount": 70.52, "10th_percentile": 70.52, "90th_percentile": 70.52, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Services; 21.5% Billed" }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 128.35, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 128.35, "10th_percentile": 128.35, "90th_percentile": 128.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "ALTERNATE BLUE CROSS [1402]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 145.24, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 145.24, "10th_percentile": 145.24, "90th_percentile": 145.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BEECHSTREET [176]", "plan_name": "PH BEECHSTREET", "standard_charge_dollar": 262.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "Outpatient; 80% Billed", "median_amount": 262.4, "10th_percentile": 262.4, "90th_percentile": 262.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient; 80% Billed" }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS", "standard_charge_dollar": 55.53, "standard_charge_percentage": 16.93, "standard_charge_algorithm": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 55.53, "10th_percentile": 55.53, "90th_percentile": 55.53, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 16.93% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE OPTIONS SELECT", "standard_charge_dollar": 45.89, "standard_charge_percentage": 13.99, "standard_charge_algorithm": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 45.89, "10th_percentile": 45.89, "90th_percentile": 45.89, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 13.99% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS BLUECHOICE PREFERRED", "standard_charge_dollar": 46.81, "standard_charge_percentage": 14.27, "standard_charge_algorithm": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 46.81, "10th_percentile": 46.81, "90th_percentile": 46.81, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 14.27% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS HMO", "standard_charge_dollar": 128.35, "standard_charge_percentage": 39.13, "standard_charge_algorithm": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 128.35, "10th_percentile": 128.35, "90th_percentile": 128.35, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP All Other Services; 39.13% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "BLUE CROSS BLUE SHIELD [1401]", "plan_name": "PH BCBS PPO", "standard_charge_dollar": 145.24, "standard_charge_percentage": 44.28, "standard_charge_algorithm": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 145.24, "10th_percentile": 145.24, "90th_percentile": 145.24, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "No historical claim; OP All Other Services; 44.28% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CARELON BEHAVIORAL HEALTH [159]", "plan_name": "PH VALUE OPTIONS BHO", "standard_charge_dollar": 164.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 164.0, "10th_percentile": 164.0, "90th_percentile": 164.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "ALL OTHER OP; 50% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA ALTERNATIVE", "standard_charge_dollar": 61.34, "standard_charge_percentage": 18.7, "standard_charge_algorithm": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 61.34, "10th_percentile": 61.34, "90th_percentile": 61.34, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 18.7% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BEHAVIORAL BHS", "standard_charge_dollar": 262.4, "standard_charge_percentage": 80.0, "standard_charge_algorithm": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 262.4, "10th_percentile": 262.4, "90th_percentile": 262.4, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEFAULT; 80% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "CIGNA HEALTH PLAN [178]", "plan_name": "PH CIGNA BROAD", "standard_charge_dollar": 97.09, "standard_charge_percentage": 29.6, "standard_charge_algorithm": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 97.09, "10th_percentile": 97.09, "90th_percentile": 97.09, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Outpatient; 29.6% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "COMPSYCH [112]", "plan_name": "PH COMPSYCH", "standard_charge_dollar": 246.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "Default %; 75% Billed", "median_amount": 246.0, "10th_percentile": 246.0, "90th_percentile": 246.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Default %; 75% Billed" }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH AETNA", "standard_charge_dollar": 186.3, "standard_charge_percentage": 56.8, "standard_charge_algorithm": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 186.3, "10th_percentile": 186.3, "90th_percentile": 186.3, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 56.8% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount." }, { "payer_name": "FIRST HEALTH PLAN [6034]", "plan_name": "PH FIRST HEALTH", "standard_charge_dollar": 246.0, "standard_charge_percentage": 75.0, "standard_charge_algorithm": "All Other OP Services; 75% Billed", "median_amount": 246.0, "10th_percentile": 246.0, "90th_percentile": 246.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP Services; 75% Billed" }, { "payer_name": "HEALTH'S FINEST NETWORK [126]", "plan_name": "PH HFN", "standard_charge_dollar": 278.8, "standard_charge_percentage": 85.0, "standard_charge_algorithm": "OUTPATIENT; 85% Billed", "median_amount": 278.8, "10th_percentile": 278.8, "90th_percentile": 278.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OUTPATIENT; 85% Billed" }, { "payer_name": "HEALTHLINK [125]", "plan_name": "PH SEIU HEALTHLINK", "standard_charge_dollar": 164.0, "standard_charge_percentage": 50.0, "standard_charge_algorithm": "Outpatient Services; 50% Billed", "median_amount": 164.0, "10th_percentile": 164.0, "90th_percentile": 164.0, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "Outpatient Services; 50% Billed" }, { "payer_name": "MAGELLAN BEHAVIORAL HLTH [136]", "plan_name": "PH MAGELLAN BHS", "standard_charge_dollar": 196.8, "standard_charge_percentage": 60.0, "standard_charge_algorithm": "OP DEF; 60% Billed", "median_amount": 196.8, "10th_percentile": 196.8, "90th_percentile": 196.8, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "OP DEF; 60% Billed" }, { "payer_name": "MULTIPLAN/PHCS [142]", "plan_name": "PH MULTIPLAN/PHCS", "standard_charge_dollar": 229.6, "standard_charge_percentage": 70.0, "standard_charge_algorithm": "All Other Rev; 70% Billed", "median_amount": 229.6, "10th_percentile": 229.6, "90th_percentile": 229.6, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other Rev; 70% Billed" }, { "payer_name": "THE ALLIANCE [1703]", "plan_name": "PH THE ALLIANCE", "standard_charge_dollar": 210.67, "standard_charge_percentage": 64.23, "standard_charge_algorithm": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges.", "median_amount": 210.67, "10th_percentile": 210.67, "90th_percentile": 210.67, "count": "0", "methodology": "percent of total billed charges", "additional_payer_notes": "All Other OP; 64.23% Billed, and; Pricing Extension - NM HB XR PRC - LESSER OF TERMS OR 80% OF CHARGES; Note: Paid contractual rate, which is the lesser of contractual rate and 80% of charges." }, { "payer_name": "UNITED HEALTHCARE [158]", "plan_name": "PH UHC ALL OTHER", "standard_charge_dollar": 167.61, "standard_charge_percentage": 51.1, "standard_charge_algorithm": "Table 5 Services; 51.1% Billed, and; Pricing Extension - HB XR PRC - Lesser Of Terms Or Total Billed Amount; Note: Paid at contractual rate, which is the lesser of contractual and 100% of charges. Total pmt for all lines paid so far is less than 100% of claim billed amount.", "median_amount": 167.61, "10th_percentile": 167.61, "90th_percentile": 167.61,